Ministry Reports

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-TermCare 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 positionor interests of the associations or organizations with which membersare affiliated.

Table of Contents


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Executive Summary

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 :
* Ministry of Health was renamed mid-1999 to Ministry of Health and Long-Term Care)

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 aphysician 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 arepresently 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.


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Recommendations

The Telehealth Task Force makes the following recommendations for a Telehealth Education and Triage/Advisory Service :

Information/Educational Service Issues
  1. A new information and educational service shall be co-ordinated with existing local and provincial services, andhave referral processes to specialized services.
  2. Information and education services shall be provided using a communications framework that includes all vehicles (e.g.,handbooks, tapes, newsletters, websites) available. Selection of themost appropriate tools shall be based on the most useful, practical and cost effective format for the type of information being provided and the population being served. The library of health information and education tapes shall be comprehensive and up-to-date. Automated systems shall 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 shall be reviewed regularly.
  3. Callers seeking health information (not triage) would be transferred to an automated library of tapes. Automated information systems shall offer callers the option of speaking to an individual if the information on the tapes has not adequately addressed their questions.
  4. Telephone access to the service shall be available to all residents of Ontario, even when outside the Province. The volumeof calls received from non-residents should be monitored so that action can be taken if volumes become unacceptable or other issues arise.
  5. Provisions shall be made to ensure that callers with rotary phones have full access to any automated systems.
  6. Services shall be provided in the two official languages at the outset, with a view to expanding to more languages over time.
  7. Disease prevention and management services, if provided, shall be consistent with the principles for a telehealth service.
  8. Where private sector partnerships are considered,care shall be taken to avoid conflict of interest situations and ethicalissues related to the endorsement of products. All aspects of diseasemanagement, for example diet and exercise, shall also be addressed.

Triage Service Issues

Provincial Advisory Committee
  1. There shall be one independent advisory committee for the province, to provide advice to the Ministryof Health on standards, business, ethics, quality assurance, funding,technical and scientific issues, and service evaluation.Individual call centres (if there is to be more than one call centre) could have sub-committees to advise on local issues.
  2. The provincial advisory committee shall have balanced representation from nurses, physicians and other health professionals representing a broad range of healthcare interests, e.g.,mental health, social work and consumers, as well as individuals withbusiness, ethics, technical and quality assurance expertise. Membersshall provide regional and community representation.
  3. The provincial advisory committee shall developcriteria to ensure the appropriateness of community resources to whichcallers may be referred (e.g., recognized provincial services).
  4. The provincial advisory committee shall have access to all aggregate call centre information and policies. Further review of existing services has indicated that the provincial advisory committee may also need access to individual case data for complaint resolution or other process issues.
  5. The provincial advisory committee shall be involved,in an advisory capacity, in the process for issuing a request for proposals for a telephone health education and triage/advisory service,but shall not participate in the selection of a vendor or service supplier.
  6. The provincial advisory committee shall be independent of any telehealth service, funded directly by government and shall have dedicated funding and staff support.
Site Administration
  1. If there is more than one call centre,each call centre shall have its own administrative structure to manage operational and administrative issues.
  2. Where there is more than one call centre, governance structures may vary and could be free standing, institutionally- or community-based. Governance structures of call centres shall be funded directly by, and accountable to, the Ministry of Health. Funding shall not be part of a global budget where service is provided by a broaderhealth enterprise (e.g., a hospital).
Professional Issues
  1. The triage service shall have a medical advisor to provide a medical overview and advice as needed.
  2. The triage service shall have an appropriately qualified nursing advisor to provide nursing support and advice to the service.
  3. The telehealth service shall have physician support for functions such as decision support software review and service evaluation.Decisions related to individual callers shall be made bythe triage nurse.
  4. The first point of contact with the triage service,and the professional doing triage, shall be a registered nurse,specially trained in telephone triage and preferably with emergency roomor community experience. Telephone practice nurses shall possesshighly developed communication and interpersonal skills.
  5. Telephone practice nurses shall demonstrate the knowledge and skills necessary to provide safe and effective telephonenursing care and service, and shall use the nursing process as a framework to determine and provide the delivery of health care throughtelephone encounters with patients and their families.
  6. Health professionals shall meet the standards of their respective professional colleges in Ontario. Nurses providing telephone triage shall be registered nurses in good standing with the College of Nurses of Ontario.
  7. When conducting telephone triage, nurses shall follow the steps in the decision support software, but shall have thelatitude to exercise clinical judgement.
  8. All clinical and non-clinical staff shall have written job descriptions, qualifications and performance evaluations. The service shall have a process to verify and re-verifylicences/certification, as applicable, of all clinical staff.
  9. Each call centre shall have written organizationalcharts showing accountability and lines of communication for allpositions in the service.
Accessibility/Call Management
  1. The triage service shall aim to beavailable in as many different languages as possible and shall begin with English and French, at a minimum, to meet statutory requirements. Provisions shall be made to access any language, through telephone translation services or through individual translators at remote sites.
  2. Cultural differences shall be accommodated where possible (although these may be difficult to identify over the telephone).
  3. The triage service shall refer the caller to aphysician, community health nurse, social worker, information line,emergency room or other services, as appropriate.
  4. Linkages should be examined between emergency rooms and the telephone triage service, so that callers and non-urgent visitors to emergency rooms are referred to the toll-free number.
  5. Where calls cannot be answered immediately by a registered nurse, it would be preferable to have other trained support staff answer the call, rather than provide the caller with an automated message.
  6. Calls shall be managed as follows :
  • the average speed of answer by a live person shall be 30 seconds or less;
  • Where calls are not answered directly by triage nurses, transfer to a triage nurse shall occur within 30 seconds;
  • eighty five per cent of all calls shall be answered within 100 seconds;
  • when call volumes are heavy and callers choose to leave a message, the call shall be returned by a triage nurse within an average of 30 minutes;
  • the rate of abandoned calls or blocking (busy signals) shall not exceed 5-10 %;
  • 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 remainin a telephone waiting queue for a triage nurse or leave a message for atriage nurse.
Documentation
  1. Information collected during a triage call shall be appropriate to that necessary for the service provided.
  2. The telephone triage service shall have written policies and procedures that include: the documentation of calls,anonymous callers, abuse situations and interruption or discontinuation of service due to internal or external factors (e.g., telephone problems, weather conditions).
  3. Documentation of calls shall be done electronically,with provision for manual documentation in the event of system malfunction. It may be useful to have the caller's number displayed in the event of crisis or to be able to note the exchange from which the call is made.
  4. Situations where the triage nurse deviates from the decision support software shall be documented, including any advice or information provided and the reasons for the deviation.
Confidentiality
  1. All calls shall be treated as confidential. Callers shall have the option of remaining anonymous and shall be advised if there might be third party monitoring of calls for quality assurance or evaluation purposes. Consent for disclosure shall be obtained prior to feedback to the primary care provider or for other purposes.
  2. All records containing personal information shall be kept secure.
  3. Information shall be used solely for the purposes of performing clinical activities or the administration of the telehealth service.
  4. Information shall only be shared 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 staffand non-clinical staff within the organization who need access to implement the activities listed above.
Monitoring and Evaluation
  1. Ongoing, transparent, internal and external, third party quantitative and qualitative evaluation shall be built-in to the service and phased in over time. A continuous quality improvement program shall be implemented.
  2. Evaluation of the service shall include: outcomes;consumer, employee and physician satisfaction; access improvements;emergency room use for specific, deferrable, non-urgent events; review of advice given to callers; and, callers' compliance with recommendations.Deviation from advice contained in the software shall be evaluated.
  3. Information that shall be documented for internal evaluation purposes 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);
  • implementation of action plans to improve or correct identified problems;
  • mechanisms to communicate resulting action plans to clinical and non-clinical staff; and,
  • development of an annual quality improvement plan.
  1. The review, evaluation and update of decision support software shall be undertaken and documented at leastannually. Actively practicing physicians, telephone practice nurses and other health care providers with current knowledge relevant to the decision support software shall be involved in these processes.
  2. Regulatory bodies shall be asked to contribute to the evaluation of the service.
  3. The contract with the service provider shall include a continuous quality improvement program. Outcomes should meet contractual obligations.
  4. Where monitoring of staff is undertaken, the process shall be transparent and staff must be advised that they will be monitored and what process will be used.
  5. Telehealth nursing practice leaders shall participate in quality improvement programs and identify and apply current telephone nursing practice benchmarks to organizational goals and expectations.
  6. There shall 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, length of time for first call resolution,average speed of answer by a live person; and, average abandonment rate.
  7. Ongoing objective and systematic monitoring of the triage and health information quality management program shall be documented, and written procedures and policies shall be updated and evaluated at least annually.
Selection of Decision Support Software
  1. The decision support software used to conduct telephone triage shall be :
  • evidence based and clinically validated;
  • compatible with Canadian medical practice protocols and provincial protocols and guidelines;
  • clinically applicable for use in Ontario;
  • comprehensive in topics and content, with no gaps in information;
  • based on a philosophy of self care and education;
  • consistent, so that the same end point is reached when followed by different users in different locations;
  • flexible enough to enable the nurse to use professional judgement when providing triage and advice;
  • able to document where advice given differs from that of the software;
  • already proven elsewhere and adapted to the Canadian context;
  • able to link with specialized services such as poison control;
  • continually maintained and updated; and
  • expandable to cover topics such as mental health, disease management.
  1. Software used shall have the ability to aggregate data and to search by selected criteria.
  2. Routine reports generated by the software shall be limited to the information necessary for monitoring and evaluation.
  3. Software shall be compatible with commonly used, standard, systems.
  4. The software vendor shall estimate expected system downtime through examples of systems that are currently in operation.
  5. The vendor must be able to demonstrate ongoing product development work to ensure that the system is state-of-the-art.
  6. The vendor shall have a training program to educate staff about the decision support software.
  7. The vendor shall ensure that purchase, lease or contractual use of the software shall include ownership of all data collected and generated by the service and the right to use or publish results of evaluation and research.
  8. Provisions shall be made to incorporate any proposed revisions to the software that arise from reviews by the purchaser/lessor.
  9. Where functions are subcontracted, the contractor shall have a written contract with the subcontractor(s), ensuring that all performance standards are met and documenting lines of accountability.
Cross System Compatibility
  1. Electronic interfaces shall be compatible throughout the service and service provision shall be standardized from one area to the next.
  2. The service shall be designed to be coordinated with existing local services and other health lines such as "911", poison control, local emergency rooms and educational facilities.
Liability
  1. The vendor shall ensure that the service maintains appropriate insurance for professional liability and for errors and omissions.
  2. The registered nurses providing the service shall hold their own professional liability coverage.

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Objectives

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 :

  • improve public access to the most appropriate health service;
  • improve public access to health information in order to facilitate consumer health education and decision making;
  • improve public satisfaction with the quality of and access to health information and appropriate health services; and
  • make more appropriate use of emergency services.

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Principles

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.

  1. A telehealth education and triage/advisory service must be publicly funded and accessible to all residents of Ontario.
  2. A telehealth education and triage/advisory service must not restrict consumer choice regarding which service they may access.
  3. A telehealth education and triage/advisory service must be available for consumers to use on a voluntary rather than a mandatory basis.
  4. A telehealth education and triage/advisory service must be inclusive of physicians and nurses and others as appropriate, in all aspects of program planning, delivery and evaluation in Ontario.
  5. A telehealth education and triage/advisory service must adhere to clear standards and accountability.
  6. A telehealth education and triage/advisory service must be efficient and must contribute to the sustainability and integration of the healthcare system.
  7. An open and transparent process must be used when selecting the provider(s) of a telehealth education andtriage/advisory service.
  8. Call centres for a telehealth education and triage/advisory service must be located in Ontario.

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Summary Of Discussion On Components

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 :

  • Health Information/Education;
  • Triage; and/or
  • Disease Management.

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 anduse 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 whena 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 providedial-in access to information on a wide variety of health topics, butare 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 theprimary 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 anautomated 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 beavailable 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 tomonitor 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 aliability for the provider of the service, since the consumer initiatesthe call and thereby assumes this risk. Provisions should be made toensure 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 administrativeissues.

The Task Force determined that the service should be supported by aprovincial, independent advisory committee comprised of medical, nursingand other health professionals with expertise in relevant areas. The advisory committee would report to the Ministry of Health andparticipate in discussions regarding standards, evaluation, and service improvements, among others.

Decision Support Software (Protocols and Algorithms) - Protocols or algorithms (which are essentially decision supportsoftware) 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 beflexible 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 begiven 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 havethe 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 isobtained from the caller). However, in later discussions many members felt that this may not be desirable from a physician ora 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 furtherstages of implementation.

The service should have an ongoing, quantitative and qualitative evaluation process that is transparent, built-in to the service, andphased 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-lifethreatening events, and review of the advice given to callers should allbe included in the evaluation. Where advice differs from thatcontained 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 qualityimprovement, 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 betaken 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 aseparate 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 ethicalissues related to endorsement of products. All aspects of diseasemanagement 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.


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Summary Of Discussion On Standards

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 toexisting 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 mustmeet all CNO standards.

Although technical standards are considered to be beyond the scope ofthe 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 aprovince-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 importantrole 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 otherbody.

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 andquality assurance expertise. It was thought that the vendor(s) of theservice should sit on the advisory committee, but in a non-votingposition. 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 ora component of an existing health care service such as a hospitalcentre 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 acomparative 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 theservice. 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 clinicaloversight of clinical staff and clinical functions should be provided bya physician. There was consensus that physician support for theoverall service would be needed for functions such as protocol reviewand service evaluation, but that the physician was not to be involved in specific patient decisions. Since the service provides symptom-basedtriage, there would be no direct intervention or patient/doctorrelationship. 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 belocated 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 toinclude: the documentation of calls, anonymous callers, abuse; and,interruption or discontinuation of service due to internal or externalfactors (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) ofthe 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 thereason 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 serviceproviders/vendors/software packages were discussed, and the potential of sharing information between call centres and with other health carecentres. 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 andmonitor 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 inquality 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 shouldbe updated and evaluated at least annually.

Other information that should be documented includes : objectivesand approaches used in the monitoring and evaluation of clinical activities including documenting, investigating and maintaining complaint records to identify patterns or trends; the implementation ofaction plans to improve or correct identified problems; the mechanismsto communicate resulting action plans to clinical and non-clinicalstaff; 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 avery large undertaking, it is possible that potential vendors may enter into consortia or contracts with others to prepare a proposal. Membersgenerally agreed that where functions are subcontracted, the contractorshall have a written contract with the subcontractor(s), ensuring thatall 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 occurwithin 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 TaskForce. 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 perceivethe 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 andother 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 aprovincial 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 questionsthat would prompt vendors to provide information on how they would meet required standards and software criteria. (See Critera 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 ascoordination with existing services.


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Criteria For The Selection Of Decision Support

The following list of questions has been designed to identify criteria that could be used in selecting decision support software.

  1. What process have you used to ensure that decision support software is evidence-based ?
  2. How will you ensure that decision support software is comprehensive in topics and content, with no gaps in information ?

    Demonstrate how your protocol list has expanded over the past five years.

  3. How will you ensure that decision support software is clinically applicable for use in Ontario ?
  4. How will you ensure that the service provided is consistent with professional standards and guidelines in Ontario ?
  5. How much flexibility does the decision support software that you are providing have to enable nurses to use professional judgement ?
  6. How frequently would you expect different users of your decision support software to arrive at the same endpoint ?

    Explain.

  7. What is the process, and how often do you propose to review, evaluate and modify the decision support software ?
  8. What have you done to clinically validate your decision support software ?

    Show documentation demonstrating how research has been undertaken(e.g., use of controls, external analysis, expert opinion) and who has reviewed your software (e.g., academics, triage nurses, primary careproviders, specialists).

    What is the nursing role/input in this process ?

  9. How would you ensure confidentiality, security and appropriate storage of data ?
  10. Does your decision support software include a philosophy of self care and education ?

    Can you demonstrate a link between decision support software andrelated health information/self care information that your service would provide ?

  11. What ability does your software have to aggregate data and provide reports ?
    Can the data elements be searched individually or in unique combinations ?
  12. Does purchase, lease or other contractual use of the software include ownership of all data and the right to use or publish results of evaluation and research ?
  13. What provisions would you make to incorporate any proposed revisions to the software that arise from reviews by the purchaser/lessor ?
  14. Are you prepared to customize software to adapt it to the Canadian context ?
  15. What quality assurance standards do you have inplace, or would you propose, for ensuring monitoring of use of/adherence to the decision support software ?
  16. What documentation is required when nurses deviate from decision support software ?
  17. What clinical dispositions do you project as a result of using your decision support software (e.g., enhanced access to the healthcare system, more appropriate use of emergency services) ?
  18. How would use of your decision support software link with specialized services such as the poison control line, AIDS hotline ?
  19. Does your software have the potential to expand to cover other topics such as mental health, disease management, at a laterdate ?
  20. What product development work are you doing to ensure that your product is at the forefront of technological development and innovation ?
  21. In which languages is your software available ?
  22. With what "systems" can your software run and be compatible ?
    What is proprietary and what is standard ?
  23. Explain how your system is sustainable and can be expanded.
  24. Do you have a training program for staff about your decision support software ?
  25. What is the expected downtime for the system ?
    Give examples of downtimes that have occurred in systems that you are currently providing.
  26. What information does the system record during a triage call ?
    Does the system have the built-in ability to document free-style (e.g., where the nurse deviates from the protocol) ?

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Appendix I

Telehealth Task Force

List of Members :
Mary Beth Valentine Ministry of Health and Long-Term Care (Chair)
Jean Bickle Independent Healthcare Consultant
Dr. Ed Brown Emergency Room Physician
Karin Eisen College of Physicians and Surgeons of Ontario
Dr. Brian Gamble Family Physician
Doris Grinspun
alternate - Jacqueline Choiniere
Registered Nurses Association of Ontario
Louise Jeaurond Eastern Ontario Health Unit
Dr. Ed Lemaire The Rehabilitation Centre
Gloria Lynn
alternate - Barbara Conlon
Ontario Nurses Association
Marcia Macks
alternate - Cheri Vigar
Ministry of Health and Long-Term Care
Mary MacLeod Hamilton Health Sciences
Dr. David Mathies Family Physician
Dr. Michael McGuigan Hospital for Sick Children
Diane McLeod Victorian Order of Nurses
Barbara Mildon College of Nurses of Ontario
Louise Pitre London Health Sciences
Jackie Redmond
alternate - Sandra Golding
Hastings and Prince Edward County
Community Care Access Centre
Carol Sargo North Hamilton Community Health Centre
Judy Shanks Canadian Mental Health Association
Dr. Jack Williams
alternate - Virginia Flintoft
Institute of Clinical and Evaluative Studies
Staff Support:
Jim Wrigley Ministry of Health and Long-Term Care
Kathy Clarke Ministry of Health and Long-Term Care

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Appendix II

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 inthe 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 Ministryand 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 :

components for an effective telehealth education and triage service criteria for the selection of protocols and/or algorithms requirements for provincial standards, guidelines and regulations,including :

  • standards for telephone nursing practice;
  • policies required for an effective health service(e.g., contingency planning, disaster recovery capabilities,cross-system compatibility, etc.,).

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 :

  • components of service;
  • criteria for protocols/algorithms;
  • requirements and content of telehealth service standards; and
  • policies or regulations required for health service.
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 interes tand 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.


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Appendix III

Definitions

Abandonment Rate :

The percentage of calls offered into a communications network or telephone system (i.e., automatic call distribution system of a callcentre) that are terminated by the persons originating the call before answer by a staff person.

Algorithm :

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 interpretpatient 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 occurduring peak call volume periods and result in callers receiving a busysignal.

Disease Management :

Programs established by health care organizations, usually forchronic illnesses, that provide patient assessment, education,counselling and compliance monitoring. These programs are designed toimprove clinical outcomes and health related quality of life whileoptimizing the use of medical resources.

Guideline :

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).

Protocol :

Often used interchangeably; with Algorithm and Guideline. Defines the ongoing care or management of a broad problem or issue in six areas :

  • assessment/data collection/caller interview process;
  • classification/determination of acuity;
  • nature/type/degree of advice/intervention/direction to callers;
  • information/education of callers;
  • validation of patient understanding/verbal contracting; and
  • evaluation/follow-up/effectiveness of advice or intervention.

A protocol directs the advice/triage/education/counselling process,assisting in the organization of large amounts of significantinformation in priority order. It helps show the interrelationship ofdata, forcing consideration of all possible or likely decision choices. It directs decision making to be based upon data. The benefit of usinga 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 decisionsupport tools.


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Appendix IV

The American Accreditation Healthcare Commission/URAC
24-Hour Telephone Triage and Health Information Standards

To obtain a copy of these standards, contact :

The American Accreditation Health Care Commission/URAC
1275 K Street, N.W.
Suite 1100
Washington, DC 20005
U.S.A.


Tel : (202) 216-9010
Fax : (202) 216-9006
Website  : www.urac.org

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Appendix V

College of Nurses of Ontario
Telephone Nursing Practice : Standards for Nurses in Ontario

To obtain a copy of these standards, please contact :

College of Nurses
101 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

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Appendix VI

American Academy of Ambulatory Care Nursing
Telephone Nursing Practice Administration and Practice Standards

To obtain a copy of these standards, contact :

The American Academy of Ambulatory Care Nursing
East Holly Avenue
Box 56
Pitman, NJ O8071-0056
U.S.A.


Tel :(856) 256-2350
Fax : (856) 589-7463
Website : aaacn@ajj.com

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Appendix VII

1-800 Telephone Health Services
Components, Criteria and Standards: A Resource Bibliography

To obtain a copy of this bibliography, please contact :

Derek Bignell
Program 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

October 1999

For More Information

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