American College of Physicians: Internal Medicine — Doctors for Adults ®

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Putting an automated telephone system to work

Is faster better? Today's systems promise to streamline appointments, manage disease, reduce costs

From the April 1997 ACP Observer, copyright 1997 by the American College of Physicians.

By Amanda Loudin

A few years ago, B. Fred Bodie, MD, discovered that one of his assistants was spending huge chunks of her workday—up to six hours—on the phone reminding patients of upcoming appointments.

"We have a very busy practice," said Dr. Bodie, a dermatologist in private practice in Mobile, Ala., "and we set appointments up several weeks in advance. Because of that, we have a lot of no-shows. To combat the problem, my assistant was spending the bulk of her time calling patients to remind them of appointments."

But Dr. Bodie felt that his assistant's time would be better spent helping with paperwork and patient care. He also knew that he couldn't afford to have one person sit on the phone all day, so he began searching for a solution.

What he found was an automated phone system that not only reminds patients of upcoming appointments, but also allows them to leave messages for staff. Perhaps best of all, Dr. Bodie said, the system paid for itself in less than a year.

By installing an automated phone system, Dr. Bodie joined the growing ranks of physicians who rely on high-tech telephone systems to better manage staff—and to keep from losing what some vendors say can be as much as $2,000 a month from missed appointments.

Automated phone systems offer much more than just financial benefits, however. For most physicians, the influx of managed care means more referrals, something that phone systems can help manage. Some phone systems can also help with managed care's emphasis on preventive care by giving direct access to nurses for minor problems; others can remind patients to take medications in order to better manage a disease and ultimately reduce costs. The most sophisticated phone systems can even conduct patient surveys and give patients test results.

What about concerns that telephone technology is impersonal and can potentially harm, not enhance, the doctor-patient relationship? Dorothy B. Sweeney, vice president of The Health Care Group, a Plymouth Meeting, Pa.-based consulting firm, said that many physicians would prefer to have a human voice answering their phone, but that reality dictates that they at least consider automation. "With group practices," she said, "you've got more calls coming in and going out that you need to handle. An automated system can prevent the need to add more staff, which saves money."

Cost is another factor for physicians considering updgrading their phone system. Ms. Sweeney estimated that the types and costs of these systems vary greatly—she said that $25,000 is an average starting point—and that the number of phone lines and units is usually a key factor in how much you'll pay for a system. (See "What's available" for more information.)

Inbound vs. outbound

Generally, automated systems fall into two broad categories, outbound and inbound, although some systems incorporate features of both.

Outgoing systems can automatically call patients, usually a day or two before an appointment, and remind them of the date, time and location of an appointment. By using their telephone keypad, patients can confirm their appointment, cancel an appointment or leave a message for the office staff. Each morning, most systems run a report detailing the results of the calls, a process that takes about 15 minutes.

Physicians' offices more commonly use inbound systems that provide patients with a menu of options when they call the office. While inbound systems typically offer from one to seven choices, Ms. Sweeney recommends that physicians limit the number of choices. Typical options include appointment scheduling, billing, the ability to talk to a nurse, directions to the office and prescription refills. One of the most important features, Ms. Sweeney said, is an emergency option that puts patients through to a desk that is always staffed.

Some phone systems combine both outbound and inbound calling features. Sophisticated systems can provide appointment reminders, conduct patient surveys, report lab results and remind patients to take their medications. Some can also aid in disease management, according to Vaughn O. Leirer, PhD, president of Los Altos, Calif.-based TeleMinder. "Our system can call patients with chronic illnesses and ask a set of questions to ensure the patients are taking care of themselves," he explained. "It records the patient responses and generates a report that goes to the physician. It's preemptive in its approach to care and saves both the patients and the physicians money."

Because of their considerable cost, combined inbound/outbound phone systems are usually used by large group practices, HMOs and hospitals. Typically, the inbound functions of these systems are just as complex as those found in outbound systems. Physicians can post lab results in a database that patients can access by calling and entering a special identification number. Some systems also offer a bulletin board option that allows physicians to post information about upcoming clinics or services; patients can listen to these messages by selecting the appropriate menu item.

Physicians can also contract with nurse triage systems to give patients even more detailed information. Personal Health Advisor from Access Health Inc. in Rancho Cordova, Calif., offers 24-hour health management services, typically to members of large HMOs. Patients call the service, which is staffed by registered nurses and other clinicians, for medical advice. For example, diabetics worried that they gave themselves too many doses of insulin that day can call the service and talk to a nurse, eliminating the need for a trip to the doctor—or even worse, an emergency room.

"The system helps health plans save money by preventing unnecessary visits to the physician," explained Jan Emerson, director of corporate communications at Access Health. "At the same time, it also ensures that patients who really need an appointment get it."

Jeremy J. Nobel, MD, MPH, an internist who is senior vice president of medical affairs at Access Health Inc., said that a growing number of physicians have patients covered by telephone triage services because so many insurance plans offer some version of one. "Triage systems don't replace the physician-patient channel, but add an extension to the care a patient receives," Dr. Nobel said. "There are a large number of calls that are routine and can easily by handled by automation. A system like this frees up the staff to help those who need it."

The bottom line

Telephone triage services are typically paid for by HMOs and insurance companies, and they are typically out of the price range for most group practices. But there is also a wide range of less expensive systems that even small and mid-size groups can afford.

Wayne K. Ruth, ACP Member, a pulmonologist/allergist with Alamance Internal Medicine Associates in Burlington, N.C., said that investing in an outbound telephone system has more than paid for itself by sharply decreasing no-show rates. "This is the first piece of computer technology that has actually saved our practice money," Dr. Ruth said. "That's a strong statement to make about a system."

And despite initial fears that his patients might find the automated system impersonal, Dr. Ruth has found most patients accepting of the technology. "We've had very good response from our patients, who like the naturalness of the voice on the recording," he said.

Despite what may be considered a high price tag, many physicians say the systems are paying off in terms even managed care can understand. "I used to see about 30 or 40 patients a day," said Dr. Bodie. "Since installing my system, I've been able to increase that number to 50 or 60."

Amanda Loudin is a freelance writer based in Columbia, Md.

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