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Recommendations for a Telephone Health Education and
Triage / Advisory Service 
Final Report to the Ontario Ministry of Health and Long-Term Care
Produced by : Telehealth Task Force October 1999
Foreword
This Report to the Ministry of Health and Long-Term Care on Recommendations for a Telephone Health Education and Triage/ Advisory Service has been developed by the Telehealth Task Force. The Task Force was comprised of key health professionals who contributed significant expertise and knowledge relevant to telehealth services. The recommendations listed in this report reflect the deliberations of the Task Force as a whole and are not intended to represent the position or interests of the associations or organizations with which members are affiliated. Table of Contents
 Background
In November, 1998, the Ministry of Health * established a Telehealth Task Force to advise on policies required for the implementation and operation of an effective, provincial, telehealth education and triage/advisory service. In particular, the Task Force was asked to provide recommendations for components of the service, criteria for the selection of decision support software used by the nurses delivering the service, and standards that the service should meet. The Task Force was comprised of 20 individuals representing a broad range of health professions and interests, e.g., community health centres, mental health, clinical evaluative sciences and existing telehealth services, and was chaired by the Ministry of Health. Apart from those individuals who represented their respective professional colleges, members were selected for their specific knowledge and expertise, and not as representatives of the organizations or associations with which they are affiliated. (EDITORIAL NOTE : Telehealth Services
Telephone health services have been shown to be an efficient and effective way of supplying health information to consumers, often without requiring a visit to the health care provider, and are becoming increasingly popular in many jurisdictions in North America and elsewhere. Many types of health information can be provided over the telephone, for example information focused on specific topics such as AIDS, poison control and eating disorders, as well as more general health information and education. Telephone triage services provide advice to help callers decide whether to administer self care, see a physician or other community health service provider, or go to an emergency room. They have been successfully implemented in New Brunswick and Quebec, are being piloted in British Columbia, and are presently being considered by the Ontario Ministry of Health. The benefits resulting from a toll-free telehealth service would include improved public access to the most appropriate health service; improved public access to health information to facilitate decision making and improved public satisfaction with health services. It would also be reasonable to expect that telephone triage services would lead to more appropriate use of emergency departments. Nurses providing triage services follow protocols or algorithms (defined in Appendix III), decision support software consisting of automated checklists of clinical guidelines, to help callers make their decisions. The nurses are guided by the decision support software, but should have the flexibility to use clinical judgement, where appropriate. An educational component can be incorporated into a telehealth service by encouraging nurse interaction with callers and/or use of audio-taped educational materials. Where telephone information and triage services are being established, opportunities may exist to provide a disease prevention and management component through the same staff and facilities. Recommendation Development
The Task Force held seven meetings between November, 1998 and February, 1999, and developed 63 recommendations for a telehealth service. A number of these recommendations were based on the standards and experience of telehealth services in other jurisdictions. The recommendations are intended to guide the government in its deliberations on implementation of provincial telehealth services and will also be a useful reference for other telehealth projects. The first issue to be addressed by the Task Force was the components that would be needed to deliver a telehealth service providing health education, triage and advisory services. The discussion focussed on the selection of information/educational tools, access and language; and general issues around personnel, decision support software and call management. Confidentiality and service evaluation were also discussed. The development of standards for a telehealth service followed much the same direction as the discussion on components, but was focused on standards already in use in other jurisdictions and those currently under development by the College of Nurses of Ontario. This section of the report is organized according to structure, process and outcomes. Criteria for the selection of the decision support software (i.e., protocols or algorithms) that would be used to guide nurses delivering the telephone triage service has been dealt with in a different format. The Task Force developed a list of questions that prospective vendors would be expected to answer. The questions were designed to be open-ended to elicit detailed, informative responses while avoiding being overly prescriptive.
The Telehealth Task Force makes the following recommendations for a Telehealth Education and Triage/Advisory Service : INFORMATION/EDUCATIONAL SERVICE ISSUES
TRIAGE SERVICE ISSUES
Provincial Advisory Committee
Site Administration
Professional Issues
Accessibility/Call Management
Documentation
Confidentiality
Monitoring and Evaluation
Selection of Decision Support Software
Cross System Compatibility
Liability
Telehealth Service Objectives Telephone education and triage services can be implemented to serve a number of purposes, for example to encourage increased self care, to manage the public demand for services or to provide health information. The type of service implemented will depend on the objectives and desired outcomes. The Telehealth Task Force was asked to base its discussions on the implementation of a province-wide, 24 hour, telehealth education and triage/advisory service that would meet the following objectives :
The Telehealth Task Force identified the following principles to guide its discussions on the development of a telehealth service and also to advise the government on principles relating to the implementation of the service.
The following summary represents the outcome of discussions held at Task Force meetings. The first task of the Telehealth Task Force was to discuss the components that would be needed to deliver a toll-free education and triage/advisory service. The Task Force was asked to identify the individual components that would make up the service and to discuss the issues that should be addressed. A telehealth line can be comprised of any or all of the following services :
For each of the above services, the Task Force identified components and discussed associated issues. A number of issues were common to all services, such as the goal of making the service available in a number of different languages and the importance of ongoing evaluation of the services. For any service to be effective, sufficient outreach activities must be undertaken to ensure that the public knows what services are available, when to access them and how to access them. Information/education Service Components and Issues
There are a number of ways through which health information and education can be provided. These include live interaction with a health professional through the toll-free number, an automated library of tapes accessed through the toll-free number, healthcare handbooks, newsletters on selected topics, television, a website, fax on demand and use of community agencies and resources. Healthcare handbooks generally provide guidance on steps that individuals can take to administer self care at home, and advise on when a visit to a physician would be appropriate. For example, these are an integral component of a telehealth pilot project in British Columbia, which is focused on self care. Automated library tape services provide dial-in access to information on a wide variety of health topics, but are not directly accessible by rotary phone. Newsletters are useful when there is a need to continually send out specific information to a target group of the population. Web sites can be used to provide information to those with access to the internet, and could supplement other means of communication on health issues. It was determined that it was not necessary to undertake a cost benefit analysis regarding impacts on the health care system, since the primary focus of the service is improved public access and there was little experience in Canadian jurisdictions on which to base the analysis. It was recognized that it is important for any call centre to establish referral processes to local and specialized services as well as to explore common evaluation issues. Selection of information/educational components - Information and education services should be provided using the most appropriate tools available. Selection of the preferred means should be based on the most useful, practical and cost effective format for the type of information being provided and the population being served. In some cases, it may be more appropriate to use print media such as newsletters to target a particular audience, such as seniors who should be considering flu shots. The Task Force recognized that there may be an expectation that someone will be available to answer callers' questions, and that where automated information is provided over the telephone, i.e., by an automated library or specific taped messages, callers should have the option of speaking to an individual if the automated information has not sufficiently addressed their questions. If tapes are used they must be comprehensive and up-to-date. Automated systems should be selected from those already proven in other jurisdictions, compatible with other components of the service, (e.g., triage software) and other existing services, and must be reviewed regularly. It is important to ensure that all educational components and triage software are compatible with each other. Access and Languages - Callers could potentially access the information library by dialling directly or via the nurse on the triage line. It was thought that telephone access should be available to all residents of Ontario, even when outside the Province. Members discussed the possibility of non-residents of Ontario using the service. Although it was thought that the volume of such calls would initially be low, it was suggested that procedures be put in place to monitor calls from non-residents, so that action could be taken to restrict calls to Ontario residents, if warranted. In rural areas, access and privacy may be unavoidably compromised where telephone service is shared with others through party lines. However, where party lines exist, privacy issues should not pose a liability for the provider of the service, since the consumer initiates the call and thereby assumes this risk. Provisions should be made to ensure that callers with rotary phones have full access to any automated systems that may be established. Services should be provided in the two official languages at the outset, with a view to expanding to more languages over time. Triage Service Components
A triage service would be made up of a number of components. Personnel at one or more call centres within the Province would provide triage and advice to callers, through the use of decision support software (clinical protocols or algorithms). Where appropriate, the triage nurse should refer the caller to a community health nurse, social worker, information line or other services. The overall service would need medical advice as well as administrative and management structures. Triage Service Issues
Personnel - It was agreed that the first point of contact with the service and the professional doing triage should be a registered nurse, specially trained in telephone triage and preferably with emergency room or community experience. Members noted that since there is no face-to-face interaction with telephone triage, nurses would also require highly developed communication and interpersonal skills. The nurse would follow the protocols but should also have the latitude to exercise clinical judgement. There was much discussion over whether nurses should have the option of calling back the patient as a follow-up measure. It was agreed that calling back should not be a routine function and that provincial guidelines would be needed to determine when a call back would be appropriate, based on the College of Nurses of Ontario's standards of practice. The service should have a medical advisor to provide medical overview and advice as needed. In addition, each call centre should have its own administrative structure to manage operational and administrative issues. The Task Force determined that the service should be supported by a provincial, independent advisory committee comprised of medical, nursing and other health professionals with expertise in relevant areas. The advisory committee would report to the Ministry of Health and participate in discussions regarding standards, evaluation, and service improvements, among others. Decision Support Software (Protocols and Algorithms) - Protocols or algorithms (which are essentially decision support software) must be compatible with Canadian medical practice protocols and other relevant provincial standards. They must be comprehensive in topics and content, with no gaps in information. Consistency is very important and protocols must reach the same end point when followed by different users in different locations, although protocols must also be flexible enough to enable the nurse to use professional judgment when providing triage and advice. Although one common system would be easier to maintain, more than one set of protocols could be used provided that they reach reasonably consistent outcomes. It is important to use protocols that have already been proven elsewhere, and to have these adapted to the Ontario context. Maintenance and updating should be an ongoing practice. Call Management - The service should be available in as many different languages as possible, although it may be necessary to start with French and English. Provisions should be made to link with a language line, when necessary. Consideration should also be given to providing other languages that are not available on the language line from a remote site, with appropriately qualified and trained staff, possibly even someone's house. Cultural differences should be accommodated, where possible, although these may be difficult to identify over the telephone. Basic information must be recorded consistently and could include: topic, age and gender of caller, who provided information, information or advice requested, information or advice provided, exchange/community of call, time of day, duration, response time and language. The identification or health card number of the caller would be useful information for system monitoring and evaluation, but should be optional at the caller's discretion. Gathering and recording this information, however, must not impede the caller's access to triage. The caller should be asked to repeat the advice given to ensure that it has been understood. This should serve as an evaluation of the immediate effectiveness of the service provided. In many cases, it would be appropriate to refer the caller to other resources in the community or other types of services. It may be difficult to identify what services are available locally, since there is no single source of this information. Members suggested that criteria would be needed to screen organizations to which callers may be referred, to ensure their legitimacy. It would also be important to know where there are gaps in services and to identify alternatives. A community resource data base would be very useful for this purpose, and it was thought that the advisory committee may be able to provide screening criteria for such a data base. Confidentiality - All calls must be treated as confidential and data collected must be kept secure. Callers must have the option of remaining anonymous if they wish and must be advised if there might be third party monitoring of calls for evaluation purposes. Where consent for disclosure is to be obtained, it may be necessary to have the caller state a waiver. Feedback of key information to the primary care provider was initially considered by some to be important (provided prior consent is obtained from the caller). However, in later discussions many members felt that this may not be desirable from a physician or a patient perspective, and that it is not essential to the concept of an education and triage service. Collection of call/caller information would also be important to developing a complete health record and is essential as we move towards integrated systems. This would be more applicable to an option where there is a case management component. Evaluation - It was agreed that pilot testing of a telehealth triage advisory service would not be necessary, since similar services are known to work very well in other jurisdictions. However, the service could be phased in with evaluation that could inform further stages of implementation. The service should have an ongoing, quantitative and qualitative evaluation process that is transparent, built-in to the service, and phased in over time. As part of this evaluation, a continuous quality improvement program should be implemented. Evaluations should be conducted internally, as well as by a third party, and a commitment to change in response to evaluation results should be included in the contract with the service provider. Clinical, financial and system outcomes, consumer satisfaction, access improvements, reduction in emergency room use for non-life threatening events, and review of the advice given to callers should all be included in the evaluation. Where advice differs from that contained in the protocol used, it would be necessary to document why that approach was taken. The software should have the capability to record reasons for deviation from the protocols and where it is necessary to switch from one protocol to another. Measuring callers' compliance with recommendations could facilitate optimization of the service and may lead to improved ability to ensure intended outcomes. Regulatory bodies will be asked to contribute to the evaluation of the service, since personnel would have to meet the standards of practice of the relevant regulatory body. Call centres generally experience peak times. Continuous quality improvement, in-service education, paperwork and other similar tasks could be completed during off-peak hours. DISEASE PREVENTION AND MANAGEMENT
A call centre could also play an important role in disease prevention and management. Optional services could include disease management for conditions such as asthma, diabetes and hypertension; disease prevention such as referrals for flu shots or mammograms; and even research such as clinical trial follow-up. These could be provided by the public sector alone or in partnership with private sector parties. There was concern that these services could potentially overlap with other public health services and that particular care would have to be taken to ensure service augmentation, rather than duplication, especially with provision of primary care services. It was thought that these types of services could also be beneficial to areas without particular services and those with special populations. Any services provided should be consistent with the stated principles for a telehealth service. There was some discussion that health promotion outreach services could be provided in the off-peak periods experienced by the triage service. It was generally thought that this would probably need to be a separate service and a full time commitment, to avoid the potential for conflicting resource needs between the two services. It was noted that excess capacity should not be deliberately built-in to the design of the service. Disease prevention and management services should be appropriately planned and could be phased in where needed first. It was recognized that there could be the potential for partnerships that could generate revenues that would help to offset the costs of the infrastructure. Where private sector partnerships are considered, care should be taken to avoid conflict of interest situations and ethical issues related to endorsement of products. All aspects of disease management and health promotion, for example diet and exercise, could be addressed. Further concerns included widespread unsolicited calls which could be bothersome to consumers and that calls to individuals on party lines could pose privacy issues.
The quality and effectiveness of a telehealth service will, in part, be determined by the standards that are used in the contract with the service provider. It is therefore important to identify and set standards that are clear, achievable and comprehensive. The Task Force discussed a broad range of items for which standards would be required. These have been assigned under the headings of Structure, Process and Outcomes. Since there are numerous telephone triage services already operational in other jurisdictions, the Task Force was able to refer to existing standards as a basis for its discussions and compare them to what might be appropriate in the Ontario context. The most comprehensive set of standards available to the Task Force was obtained from the American Accreditation Healthcare Commission/URAC (URAC), which has recently developed accreditation standards for 24-Hour Telephone Triage and Health Information (Appendix IV). At least four services have received URAC accreditation and many more have applications underway. In addition to using the URAC standards, the Task Force referred to the College of Nurses of Ontario's (CNO) consultation paper on Telephone Nursing Practice: Standards for Nurses in Ontario (Appendix V) and the American Academy of Ambulatory Care Nursing's (AAACN) Telephone Nursing Practice Administration and Practice Standards (see address in Appendix VI). Since the call centre(s) providing the telehealth service would be located in Ontario, it is assumed that nurses providing the service must meet all CNO standards. Although technical standards are considered to be beyond the scope of the Task Force, it was recognized that these requirements would need to be developed before the service could be implemented. Some Task Force members felt that there should be some opportunity for Task Force involvement when technical standards are being developed. STRUCTURE
Advisory Committee
Many existing telephone health information and triage services are guided by an advisory committee comprised of health professionals with expertise in relevant areas. It was considered important, therefore, to discuss the potential role and function of an advisory committee in the Ontario setting, and whether one would be needed to advise on a province-wide service, or each call centre (if it is determined that there will be multiple call centres) should have its own advisory committee. Members agreed that there should be just one advisory committee to the province, rather than one for each call centre, and that sub-committees could be struck to address specific needs as they arise. It was noted, however, that regional services could also have advisory committees to assist and advise on local issues. Task Force discussions on possible roles and functions reached the conclusion that a provincial advisory committee would play an important role in providing advice to the Ministry of Health on standards, quality assurance, funding, ethical, technical and scientific issues and service evaluation. It was agreed that the above would comprise the primary functions of the advisory committee and that governance and service delivery would be more appropriately provided by another body(s). The advisory committee could be involved in the Request for Proposals process for the service, but would not participate in the selection of a vendor. Members noted that the advisory committee should be independent and should be directly funded by the government. The advisory committee should have dedicated funding and staff support, so that it would not be inadvertently affected by changes in funding or resources for any other body. Members proposed that the advisory committee should have balanced representation from nurses, physicians and other professionals representing a broad range of healthcare interests, e.g., mental health, social work and consumers, as well as individuals with technical and quality assurance expertise. It was thought that the vendor(s) of the service should sit on the advisory committee, but in a non-voting position. In addition to bringing specific areas of expertise to the committee, members should be selected to provide regional and community representation, as relevant. To facilitate its function of advising on the evaluation of the telehealth service(s), it was noted that it would be important to ensure that the advisory committee has access to all aggregate call centre information, policies, etc. Governance and Administration
It is possible to deliver a province-wide telephone health education and triage/advisory service from a single call centre. Some members feel this would be preferable, to enable economies of scale. Others would prefer to have the service delivered by two or more call centres, to provide back-up in an emergency. If it is determined that there would be more than one call centre for the province, the Task Force concurred that the governance structure may vary for each call centre. The governance model could be institutionally or community based, and either a single-focus service or a component of an existing health care service such as a hospital centre or other transfer payment agency. Funds would not be part of a global budget if the service was to be provided by an institution. In discussions on the governance structure of a telehealth service, it became clear that the suitability of the governance structure would be highly dependent on whether there are one or more service/decision support software providers in the longer term. It was agreed that both short and longer term strategies would need to be developed. There was no conclusion as to whether there should eventually be only one software vendor/provider for the service. Key issues related to consistency with high quality outcomes, the ability to interface between sites and the assurance that provincial standards are incorporated into the service delivery. A future decision should be based on a comparative evaluation of the different services in Ontario (e.g., Primary Care Reform pilot project, the Northern Ontario telephone triage service and the provincial telehealth service), as well as consideration of relevant evaluation results and other information from other jurisdictions. The evaluation framework should be developed by key stakeholders including nurses, physicians and other healthcare professionals representing a broad range of healthcare interests (e.g., mental health, social work, consumers), as well as individuals with technical and quality assurance expertise, and approved by the Advisory Committee. Professional Issues
In developing a framework for a telephone health information and triage service, it would be important to clearly describe the qualifications and roles of the staff that will be needed to deliver the service. Experience in other jurisdictions indicates that most telephone triage services are delivered through registered nurses and have a medical director as a consultant to the service. In its deliberations, the Task Force agreed that the service should be delivered through registered nurses, and physician support would be important. Members did not all agree with the URAC standard that clinical oversight of clinical staff and clinical functions should be provided by a physician. There was consensus that physician support for the overall service would be needed for functions such as protocol review and service evaluation, but that the physician was not to be involved in specific patient decisions. Since the service provides symptom-based triage, there would be no direct intervention or patient/doctor relationship. In circumstances where medical advice is needed, the triage nurse will refer callers to a physician or to an emergency room, and will always err on the side of caution. With this in mind, medical support would not need to be available at all times, or necessarily be located on-site. There was much discussion on responsibility for clinical oversight of clinical staff. After considerable dialogue, it was agreed that the triage service should have an appropriately qualified nursing advisor to provide nursing support and advice to the service. The Task Force agreed that all clinical and non-clinical staff shall have written job descriptions, qualifications and performance evaluations, and that the program shall have a process to verify and re-verify licences/certification, as applicable, for all clinical staff. The Task Force also agreed that written organizational charts should be required that show accountability and lines of communication among all members of the health care team. The organizational structure should include the interdisciplinary team and may include, but would not be limited to a medical advisor, nursing advisor, nursing educator, telephone nurses and clerical and/or clinical telephone nurse support staff. The chief administrator of the service should have expertise in business management and would not necessarily have a background in health care. The Task Force agreed that telephone nurses shall demonstrate the knowledge and skills necessary to provide safe and effective telephone nursing care and service, and it was determined that the person providing triage must be a registered nurse registered with the College of Nurses of Ontario. It was understood that registered nurses would use the nursing process as a framework to determine and provide the delivery of healthcare through telephone encounters with patients and their families, consistent with CNO standards. It was noted that ongoing staff development would be important. There was much discussion on whether a registered nurse or other appropriately trained, regulated, healthcare professional should be the first person to answer patient calls. It was recognized that this may not be practicable at all times, e.g., during peak calling periods. One alternative could be to have the call transferred automatically to other sites, if available. If calls cannot be answered immediately by a registered nurse, some members felt that it would be preferable to have other medically trained support staff answer the call, rather than provide the caller with an automated message. The potential for registered practical nurses in non-triage health information roles was discussed briefly and it was agreed that appropriately trained registered practical nurses could deliver the health information part of the service. There was general support for standards pertaining to the call centre working environment. It was thought that Ontario occupational health and safety standards would adequately address working conditions. Documentation
The Task Force supported URAC requirements that information collected should be limited to that necessary for triage and health information, and that the service should have written policies and procedures to include: the documentation of calls, anonymous callers, abuse; and, interruption or discontinuation of service due to internal or external factors (e.g., telephone problems, weather disasters). The Task Force reiterated points made in its earlier discussions that data to be documented could include the age and gender of caller, the name of the person who provided information and their relationship to the patient, the patient's name, the location (exchange or community) of the caller, the time of day, call duration, response time and language. It would be important to record any advice given that differs from that in the protocol and why it differed. Additional information that could be collected, depending on the reason for the call, is found in the CNO discussion paper. This includes breathing status, level of consciousness, caller's concerns/reason for calling (including history of concern and signs and symptoms), allergies, weight, past medical history, current medications and physician, as relevant. Ideally, information would be provided that identifies the caller to the system (unless the caller wishes to remain anonymous). In this way, a data base can be built and historical information gathered. Identification by health card number would be ideal, but downloading of existing health card information into the system is not contemplated at this time. It was suggested that although identification by health card number should be optional, provisions should be made at the outset to enable the system to accept this information, for implementation at a later date. Members agreed that documentation of calls should be done electronically, with the provision for manual documentation in the event of system malfunction. Members also suggested that it may be useful to have the caller's number displayed in the event of crisis or simply to be able to note the exchange from which the call originates. They noted that it was important to document, at least annually, the review, evaluation, and updating of clinical decision support tools (with involvement from actively practicing physicians and other providers with current knowledge relevant to the clinical decision support tools. Members agreed that telephone practice nurses could participate in clinical and health care systems research. Information collected should be used to identify the need to modify protocols as well as monitor the nursing process. Issues related to a single versus multiple service providers/vendors/software packages were discussed, and the potential of sharing information between call centres and with other health care centres. Task Force members noted that much will be dictated by factors including : privacy legislation, the model(s) of service chosen, funding levels, technological capabilities, etc. The software package must have the ability to aggregate data and the ability to search by selected criteria, although it was recognized that routine reports should be limited to information that is necessary for monitoring and evaluation. While members thought it of value to be able to track follow-through with advice given, a mechanism for how this should be accomplished was not identified, other than to identify the issue as an evaluation criterion. It was recognized that while the Primary Care Reform pilot sites will have the ability to establish and monitor a model of service that links directly back to the physician, other, broader models or pilots were unlikely to have this capacity. Confidentiality
Confidentiality of personal health information is important in the provision of any health care service, and regulations or standards have been developed for more traditional services that address this concern. Due to the unique nature of telephone health services (i.e., provided over the telephone, electronic management of data), additional steps may need to be taken to ensure that patient privacy is protected. To protect privacy, the Task Force thought that callers must have the option of remaining anonymous if they wish and must be advised if there might be third party monitoring of calls for quality assurance or evaluation purposes. Consent for disclosure of information would need to be obtained prior to feedback to the primary care provider or for other purposes. The service must meet the standards of professional colleges and other healthcare facilities, and records must be secure. Members agreed with requirements that information shall be used solely for the purposes of performing clinical activities or the administration of other services in the health care organization (i.e., triage, health information, demand management, disease management, quality management, utilization management). Information shall be shared only with those entities or individuals external to the organization who contractually or statutorily have authority to receive such information or who are otherwise specifically authorized and shared only with clinical staff and non-clinical staff within the organization who need access to implement the activities listed above. Some members were concerned that information must be available for research purposes, however, it was felt that the preceding standard is broad enough to encompass research activities. It was noted that external research generally used anonymized and aggregate data. Monitoring and Evaluation
Ongoing monitoring and evaluation will be key components of any telephone health service and will be essential to determine whether the service is meeting its stated objectives. This will be the responsibility of the provincial Advisory Committee. In addition to internal reviews, third party quantitative and qualitative evaluation should be built-in to the service. Task Force members advised that where monitoring of staff is undertaken, the process should be transparent and staff must be made aware of the monitoring before it occurs. It was agreed that a continuous quality improvement program should be implemented. Telephone practice nursing leaders should participate in quality improvement programs and identify and apply current telephone nursing practice benchmarks to organizational goals and expectations. Outcomes, compliance with nurses' recommendations, consumer satisfaction, review of advice given to callers and reduction in emergency room use for non-life threatening events are performance measures that members thought should be monitored and evaluated. Members also agreed that there should be a mechanism and process to continuously monitor, measure and review, at least monthly, all incoming triage and health information calls, including, at least average blockage (busy signal) rates, average speed of answer by a live person; and, average abandonment rate. Ongoing objective and systematic monitoring of the triage and health information quality management program should be documented, and written procedures and policies should be updated and evaluated at least annually. Other information that should be documented includes : objectives and approaches used in the monitoring and evaluation of clinical activities including documenting, investigating and maintaining complaint records to identify patterns or trends; the implementation of action plans to improve or correct identified problems; the mechanisms to communicate resulting action plans to clinical and non-clinical staff; and, the development of an annual quality improvement plan. There should also be a mechanism to monitor and report the aggregate disposition of all triage calls. Since a telehealth service for the Province of Ontario would be a very large undertaking, it is possible that potential vendors may enter into consortia or contracts with others to prepare a proposal. Members generally agreed that where functions are subcontracted, the contractor shall have a written contract with the subcontractor(s), ensuring that all performance standards are met. This would make lines of accountability clear and provide some protection where there is more than one vendor/party involved in delivery of the service, so that the final accountability would rest with the primary vendor/contractor. OUTCOMES
The quality of the service should be consistently high, due to the continuous quality assurance program, and this should be reflected in customer satisfaction and decreased anxiety about health symptoms. The number of callers to the service should grow rapidly at the beginning, as the public becomes aware of the service, and should level-off as the health education component provides individuals with improved capacity and confidence to undertake self care. These would be measured through surveys of new and repeat callers. Utilization patterns of emergency and primary care services would be expected to change. The number of visits may not necessarily decrease, but the reasons for visits could be expected to change to reflect more appropriate usage of these services. Accessibility/Call Management
Public accessibility to the service and the speed with which callers are connected to the triage nurse will significantly influence public satisfaction with and use of the service. These outcomes will be measured through ongoing monitoring and evaluation of calls to indicate whether the service is meeting its prescribed standards. Standards for call management and service accessibility should address such issues as how quickly calls must be answered, how quickly messages must be returned and what percentage of abandoned calls or busy signals is acceptable. To some extent, these variables will be influenced by the level of funding assigned to provide the service. The Task Force did not debate criteria used in other jurisdictions. Having agreed that the first person to answer the call should be a registered nurse, where possible, members were prepared to accept the URAC standards that the average speed of answer by a live person should be within 30 seconds and transfer to clinical staff person should occur within 30 seconds. Similarly, there was support for New Brunswick's standard of 85 % of calls being answered within 100 seconds. Members decided that while it would be difficult to determine what the appropriate standard should be at the outset, some base standard should be set and monitored to measure its efficacy. Immediate access to a clinical response is the preferred outcome. Where call volume is heavy and callers choose to leave a message, URAC and New Brunswick require that a clinical staff person should return the call within an average of 30 minutes. This was agreeable to the Task Force. A call abandonment or blocking (busy signal) rate of 5 to 10 % (URAC and New Brunswick, respectively) was considered, and some members thought that 10 % may be too high. Although a live response is preferred, the Task Force agreed that when callers cannot access a live person within the prescribed times, a recorded message shall instruct the caller to either hang up and call "911" or local emergency services, if the situation is perceived by the caller to be an emergency. Instructions to callers who do not perceive the situation to be an emergency shall be to remain in a telephone waiting queue for a triage nurse or leave a message for a triage nurse. Cross-System Compatibility
Where there is more than one service provider, call centre or set of protocols or algorithms, measures may be needed to ensure that all components of the service are compatible with each other. It was noted that it would be important to ensure that electronic interfaces are compatible and that service provision is a consistent standard from one area to the next. Task Force members pointed out that the service should be designed to be compatible with existing local services and other health telephone lines such as "911", poison control, local emergency rooms and educational facilities. Selection Of Decision Support Software
The Task Force discussed the criteria by which software should be selected, and the pros and cons of having more than one set of protocols or algorithms were debated. The Task Force was asked for its recommendation on whether there should be one or more vendors of software decision support tools for the entire province. The benefits of a single vendor include: consistent software, compatible data among call centres, clearer lines of accountability and a concentrated job market for registered nurses in the vicinity of the call centre(s). Members noted that it may be useful to test different software on a pilot or similar basis prior to determining the best approach for a provincial service. It was thought that the Provincial Advisory Committee should be involved in the Request for Proposals process, advising on appropriate criteria, for example, but not in the actual review of proposals and selection of a vendor. The Task Force developed a series of questions that would prompt vendors to provide information on how they would meet required standards and software criteria. (See CRITERIA FOR THE SELECTION OF DECISION SUPPORT SOFTWARE). IMPLEMENTATION ISSUES
Implementation of a provincial toll-free telehealth service was discussed briefly, from the perspective of coordination among services providers if more than one call centre is selected. Linkages with the Primary Care Reform networks would need to be considered, as well as coordination with existing services.
The following list of questions has been designed to identify criteria that could be used in selecting decision support software.
TELEHEALTH TASK FORCE
List of Members :
TELEHEALTH TASK FORCE TERMS OF REFERENCE
Before establishing the Telehealth Task Force, the Ministry of Health developed the following terms of reference : Background
There is growing recognition of the likely benefits of telephone health services, and of the need for government policy in this area. There is a proliferation of telephone health services available to the public (e.g., services offered by private companies for a user fee, by broader public sector organizations such as hospitals/community organizations, and through employers who have contracted for telehealth through health management companies). In addition, Primary Care Reform (PCR) will include after hours telephone advice for rostered patients in the five sites. Currently, there are no core quality standards, guidelines or criteria that apply to the operation of telehealth services in Ontario, the absence of which has implications for the public interest. In order to protect the public interest and establish a basis for funding accountability and evaluation for new initiatives, the Ministry of Health is establishing a Telehealth Task Force to advise the Ministry and inform government policy decisions in the coming months. Objectives of the Task Force
The Telehealth Task Force will advise on policies required for the implementation and operation of an effective provincial telehealth service, in particular :
The Telehealth Task Force may also be asked to discuss the need for provincial policies or regulations and to advise on issues such as the coordination of various telehealth initiatives. Deliverables
The Telehealth Task Force will produce recommendations that will address :
Timelines
November 1998 to February 1999. Chair
The Task Force will be chaired by Mary Beth Valentine, Director, Program Policy Branch, Ministry of Health. Membership
Membership will consist of health providers with specific interest and expertise related to telehealth that meets the requirements of the Task Force. Members will not sit as representatives of any organization or institution, but will be selected from among various backgrounds, including the medical and nursing professions.
Definitions
ABANDONMENT RATE :
The percentage of calls offered into a communications network or telephone system (i.e., automatic call distribution system of a call centre) that are terminated by the persons originating the call before answer by a staff person. Written clinical questions using a branch chain logic (flow chart). Often used interchangeably with Guideline and Protocol. Algorithms prescribe what steps to take given particular circumstances or characteristics. Some algorithms also include designated points in the decision-making process where physicians and other caregivers need to discuss with patients or families their preferences for particular options. Algorithms rely on nurses' ability to analyse and interpret patient responses to clinical questions. (See Guideline, Protocol). AVERAGE SPEED OF ANSWER :
The average delay in seconds that inbound calls encounter waiting in the telephone queue of a call centre before answer by a staff person. BLOCKAGE RATE :
The percentage of incoming telephone calls "blocked" or not completed because switching or transmission capacity is not available as compared to the total number of calls encountered. Blocked calls usually occur during peak call volume periods and result in callers receiving a busy signal. DISEASE MANAGEMENT :
Programs established by health care organizations, usually for chronic illnesses, that provide patient assessment, education, counselling and compliance monitoring. These programs are designed to improve clinical outcomes and health related quality of life while optimizing the use of medical resources. Guideline is sometimes seen to be a more narrative description of assessment steps that includes education and counselling text to support nurses during calls. Often used interchangeably with Algorithm and Protocol. (See Algorithm, Protocol). Often used interchangeably; with Algorithm and Guideline. Defines the ongoing care or management of a broad problem or issue in six areas :
A protocol directs the advice/triage/education/counselling process, assisting in the organization of large amounts of significant information in priority order. It helps show the interrelationship of data, forcing consideration of all possible or likely decision choices. It directs decision making to be based upon data. The benefit of using a protocol, algorithm, or guideline is the gain of consistency, accuracy, quality; completeness, ease, and (some) legal protection. (See Algorithm, Guideline). TRIAGE :
Classifying patients in order of clinical urgency and directing them to appropriate health care resources according to clinical decision support tools.
The American Accreditation Healthcare Commission/URAC To obtain a copy of these standards, contact : The American Accreditation Health Care Commission/URAC1275 K Street, N.W. Suite 1100 Washington, DC 20005 U.S.A. Tel : (202) 216-9010 Fax : (202) 216-9006 Website : www.urac.org
College of Nurses of Ontario To obtain a copy of these standards, please contact : College of Nurses101 Davenport Road Toronto, Ontario M5R 3P1 Canada Tel : 416-928-0900 or 1-800-387-5526 Website : www.cno.org or E-mail : cno@cnomail.org
American Academy of Ambulatory Care Nursing To obtain a copy of these standards, contact : The American Academy of Ambulatory Care NursingEast Holly Avenue Box 56 Pitman, NJ O8071-0056 U.S.A. Tel : (856) 256-2350 Fax : (856) 589-7463 Website : aaacn@ajj.com
1-800 Telephone Health Services To obtain a copy of this bibliography, please contact : Derek BignellProgram Policy Branch Ministry of Health and Long-Term Care Tel : 416-327-8540 Fax : 416-327-8879 E-mail : Derek.Bignell@moh.gov.on.ca | |||||||||||||||||||||||||||||||||||||||||||||
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