Direct Notification Systems Outperform Live Operators
In the past several weeks I’ve been speaking with providers and practice managers frustrated by the quality of after-hours communications. Despite dissatisfaction with their current service, many providers have the impression that a live service is somehow better for patient care. I’ve been skeptical and have been looking for some objective data on this topic. I’ve just found it.
One of the few peer reviewed studies to examine the comparative effectiveness of live –vs- automated communications systems was published about ten years ago by Moss and colleagues in the Department of Medicine at Emory University (where I spent years laboring on my Ph.D.!). The article can be accessed for free here or can be downloaded as a PDF.
The overarching goal of the study was to characterize clinician response times to pages originating from the intensive care unit (ICU) at two university-affiliated hospitals. The study examined a total of 402 pages sent to 166 different physicians when the page was either a) sent directly to the provider or b) through a 3rd party intermediary such as an answering service or a physician’s office. The difference was stark, and most certainly did not support the notion that “live is better.”
Key data points include:
- The median response time for a direct paging system was 2 minutes compared to 9 minutes for indirect systems relying on a 3rd party intermediary.
- Slow responses (≥ 15 min) were observed in 40% of all indirect pages compared with only 8% of direct pages.
- Twenty-five percent of the pages placed through an indirect system (e.g. answering service) were associated with a response time of ≥ 29 min.
Collectively, these data suggest that simple, automated systems are more likely to result in timely responses to patient care issues, particularly in urgent situations.
Medical Answering Services And Documentation of Calls
In developing On Call Central as an alternative medical answering service, one of the issues we have attempted to address is provider non-compliance as it pertains to the process of documenting patient phone interactions. In research the scope of the problem, we not only spoke with a large number of providers, but looked for peer-reviewed studies examining documentation rates in clinical medicine. The results, quite frankly, are depressing and underscore the need for new methods of ensuring documentation of phone interactions.
Two Peer Reviewed Studies
In contrast to face-to-face interactions occurring during normal office hours, after hours phone calls are documented poorly, if at all. Though the number of studies examining patient/physician phone interactions is small, it seems likely from my recent discussions with providers that the conclusions of two older peer reviewed studies (the abstracts of which I have pasted below) remain accurate today. Emphasis mine below.
The first is a 1989 study by Hamadeh conducted at a single family practice residency program (thanks to Jan Cartwright of the Society of Teachers of Family Medicine for providing access to this now difficult-to-find study):
It is not known how many of the telephone calls received by family medicine residents get documented in a retrievable form. This descriptive study attempted to answer this question by comparing a university telephone operator’s logbook to the files of after-hours encounter slips kept in a university based family medicine training program. Over a period of 10 weeks, 38% of the calls recorded by the operator were documented by residents in a retrievable fashion. Second-year residents documented calls significantly more than third-year residents, and all residents kept better documentation on calls that concerned young children. Documentation varied significantly among individual residents but was not affected by the day or time of calls. These results suggest that having a system for recording after-hours telephone calls is not sufficient to ensure adequate documentation. Monitoring after-hours call records may provide a solution.
A multi-site study by Hannis, et. al., conducted in a sample of internal medicine residents, arrived at similar conclusions:
Little is known about the mechanisms used in internal medicine residency programs to handle patient telephone calls. To address this, a survey of internal medicine residents was conducted at 10 different internal medicine residency programs. The response rate was 76% (N = 388). Approximately 90% of the residents handled patient telephone calls. The residents saw a mean of 7 patients per week in clinic (standard deviation +/- 2) and received an average of 2 patient calls daily (standard deviation +/- 2). The mean number of patient calls received each night on-call was 3 (standard deviation +/- 6) and on weekend call days, an average of 4 patient calls were received (standard deviation +/- 8). Internal medicine residents reported spending an average of 7 minutes per call talking to the patient (standard deviation +/- 5) and 8 minutes in follow-up activities (standard deviation +/- 6). Residents reported documenting calls less than 35% of the time. Residents disagreed with the statements “I am very satisfied with my patient telephone call system” and “My patients are very satisfied with my telephone call system.” Most internal medicine residents handle a significant amount of patient telephone calls, and the systems for handling these calls are less than satisfactory. The procedures used to manage patient calls and the training for this component of practice should be improved.
Conclusions From Studies of Documenting Patient Phone Calls
Collectively these studies suggest several findings:
- Overall documentation rates are awful. With more than 60% of phone interactions going undocumented, there is an unacceptably high amount of risk for both the patient and provider.
- Documentation rates decrease as a provider’s career progresses. The Hamadeh study found that PGY3s documented calls at a significantly lower rate than PGY2s (31% -vs- 42%). While the pace of decline likely decreases over time, my conversations with providers suggests that a small minority of calls are documented, and an even smaller percentage make it into patient charts.
- Manual methods of documentation fail. Providers cannot be reasonably expected to document calls in a manual manner. Automated procedures that document and preserve the interaction are necessary to overcome the degree of provider non-compliance.
On Call Central Demonstration Video
Today we are happy to release a video this video, which demonstrates how On Call Central, a new kind of medical answering service, works and how it can benefit your practice. We love the use of the felt characters–it helps communicate how simple our software really is.
Ohio Medical Malpractice Closed Claims Report Released
As part of tort reform legislation sponsored by the Ohio State Medical Association, The Ohio Department of Insurance requires all underwriters to release statistics on paid indemnity, as well as a variety of other statistics related to malpractice liability. This data is compiled to produce the Ohio Medical Professional Liability Closed Claim Report. The most recent report, released on January 29th, 2009, covers claims paid in the 2007 calendar year. The full text of the report is available for free at the Ohio Department of Insurance. Though Ohio has experienced trends mildly favorable to providers in recent years, some of the statistics contained in the report are noteworthy, and serve as a reminder of our obligations to ensure quality patient care, and take proactive measures to protect against medical malpractice allegations. We will have a series of posts focusing on trends from the Ohio Medical Malpractice Closed Claim Report, the first of which focuses on high level findings. Subsequent posts will examine some of the details and specialty-specific data.
Overall Trends
- Most Cases Result In No Payment. The overwhelming majority of medical malpractice cases in Ohio continue to be resolved without any indemnity payment being made to the claimant. From the report:
A large majority of medical professional liability claims resulted in no payment to a claimant. Nearly 80% of the claims or 2,705, had no indemnity payments, while a little over 20% of the claims or 746, closed with an indemnity payment. The total amount paid to claimants was $235,463,393, an average of $315,635 per claim in which an indemnity payment was made.
- Total Claims Are Down Significantly. Though the percent of claims with indemnity has remained unchanged in recent years (roughly 4 of 5 claims have been dismissed in each of the past three years), the total number of claims has decreased significantly in the three years since reports have been published. Data from 2007 shows 3,451 claims, compared to 4,004 claims in 2006 and 5,051 claims in 2005. This 31% decrease relative to 2005 data is heartening, and suggests that Ohio’s tort reform efforts have (and are continuing) to produce some of the intended effects.
- Average Indemnity Is Up. Though volume has decreased, other indicators have trended sharply in the other direction. Average indemnity, which was $269,374 in 2005, is now $315,635 in the latest report–a 17% increase since the first data point. Overall, these data suggest that only the more serious malpractice allegations are being pursued, but that providers and insurance companies are having to defend themselves more aggressively in instances where patients choose to take action.
- ALAE Is On The Rise. Even when an indemnity payment is not made, there are significant investigation and legal costs related to the claim. In Ohio, the total ALAE allocation for 2007 was $103,033,668, or 43% as much as the sum of all indemnity payouts made during that same year. ALAE averaged $35,603, up over 45% since the initial 2005 data point.
- Age of Claim Matters. There is a significant correlation between the age of the claim and the size of the indemnity payout, if paid. Again, quoting the report:
The amount paid to claimants increased with the age of the claim. Of the claims that closed with an indemnity payment, 186 closed within one year of being reported and had average paid indemnity of $67,146. That figure rose to $297,935 for 202 claims closing in their second year. Nine claims closed seven or more years after being reported, having average paid indemnity of $2,785,326.
In speaking with the medical director of one prominent medical malpractice company, he offers that older cases tend to be more complex and difficult to resolve, leading to higher average indemnity payments.
