• How likely you are to be sued in a given year
• How likely you are to pay a claim in a given year
• The average size of a claim in your specialty
• Your lifetime risk of facing a claim
• The comparative risk of your specialty relative to other fields of medicine

Given our interest in helping medical groups better manage their medical malpractice risk, we thought it might be useful to slightly extend this work and distill it into a form that would be easily accessible to our uses and prospective clients.  Therefore, I reached out to Dr. Jena and requested some of the summary data (which was presented in the paper in graphical form only) and built out a simple model in Excel.  The excel model takes Dr. Jena’s data and extrapolates it to calculate the annual risk for a group medical practice.  I have placed the data Dr. Jena sent me into the linked Excel workbook so that they can access it if they like (it is in the “Input Parameters” worksheet).

The Math

Though Dr. Jena produced a lot of data, calculating your practices risk is actually fairly simple.  To calculate the annual lawsuit risk for your practice, simply calculate the annual risk that an individual physician in your speciality WILL NOT be sued (1-Ri), and raise it to the nth power, where n is the number of physicians in your practice.  (1-Ri)^n.  This is the annual probability that none of the physicians in your practice will face a lawsuit in a given year.  The difference is obviously the risk that you will be sued in a given year.  We perform similar calculations to determine the probability that someone in your practice will face a claim.  Also, we extrapolate this data out over ten years to show what your overall risk is.

The Model

Below is a brief explanatory video showing how the model works.  You can download the Excel model and use it to calculate your practice’s medical malpractice risk.  Excel Risk Model.

Click here to view the embedded video.

1. Provider notification log.   When a message is left for the on call provider, we automatically document each attempt at notifying the provider.  This audit log is accessible under the actions column for each incoming call.
2. Dissertation deterrent.  We have added a variable that allows practices to define a maximum message duration. This variable can be used to politely cut off long-winded callers after a reasonable amount of time.  The default value, currently applied to all accounts, is 90 seconds.  Within a few days you will be able to modify this variable via the On Call Central web interface.
3. Updates to call schedule management.  We have updated the call schedule management portion of the On Call Central telephony application such that it notifies the user who is currently on call for each call schedule prior to asking the user to put someone new on call. This functionality only applies to accounts with multiple call schedules.

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.

We Didn’t Do This Alone

We would like to thank several parties for their assistance and technical guidance in navigating the complexities of the Alaska market. Foremost, we would like to thank the people at Tekmate, in particular Alan Zirkle, Buddy Gant, Jared Armstrong, and Shawn Fuller. Not only do these gentlemen know their stuff, but they have been very generous in providing us test machines on which we have been able to optimize our application. We would also like to thank the people at the TelAlaska NOC and the engineers at Alaska Communications Systems for their considerable help. Last, we would like to thank the engineers at Sangoma Technologies, in particular Marc Celsie and Moises Silva, for their assistance in configuring their hardware, which powers core features of this new roll-out.

Why Do This?

The reasons for dedicating resources to Alaska are several, and have become obvious in the past few months. First, Alaska is the only rate center in the United States where major voice over IP providers do not yet issue local phone numbers. We wanted to be able to offer Alaska clients 907 area code numbers, and without establishing a physical infrastructure in Alaska, we would be stuck issuing out of state numbers and 1-800 numbers to clients. Though not a major issue in most cases, we have encountered at least one instance where the lack of a local number made it difficult for clients to dial into their On Call Central account (e.g. when being prompted for a long distance access code at a hospital phone terminal). Second, we were encountering intermittent latency issues that rendered some VoIP calls unusable. This was a fundamental engineering issue resulting from the significant physical distance between Alaska and our Dallas data center. For our Alaska customers, a two party voice call was making a ~10,000 mile round trip between Anchorage and Texas.

What Did We Do?

To resolve these two issues, we embarked on an engineering project that involved, among other things, reconfiguring the telephony portion of the On Call Central code application. Specifically, we moved these customers away from VoIP-based telephony to a system that uses a voice T1 (aka PRI) line. Overall, this entailed what is for us a major investment in time and money, but we expect it to pay off in increased reliability and high quality audio.

Click here to view the embedded video.

1. Reliability. Most clients call us because they are very unhappy with the reliability of their medical answering service. Live operators are typically poorly trained, and the industry is burdened with high employee turnover rates. Quality varies greatly from day to day (and hour to hour) based on the operator who answers the phone. On Call Central establishes a consistent protocol that is followed each time a patient or other provider contacts your practice, and provides a level of reliability atypical of a medical answering service.
2. Professionalism. Operators who receive calls for OB/Gyns and cardiologists require a different skill set and should be held to higher professional standards than those receiving calls from plumbers and electricians. Unfortunately, it is difficult or impossible to continually assess the professionalism of a live medical answering service, and many providers realize the problem only after a patient complaint. Establishing a consistent protocol, and automating the handling of calls ensures that your patients receive a consistent, professional interaction day or night.
3. Privacy & HIPAA. Live medical answering services constitute an unnecessary “middleman” HIPAA risk that can put your practice at risk for the disclosure of protected health information. A well-designed, secure automated system is far superior to a live operator when it comes to protecting sensitive patient information. Since On Call Central enables direct provider/patient communications with no middleman, privacy risks are significantly reduced.
4. Call Schedule Management. The majority of medical answering services use antiquated technology to manage the call schedule. Most medical answering services require practices to fax a copy of the call schedule and call in any last minute modifications. On Call Central puts you in control. Members of your practice can update the call schedule at any time through the On Call Central web interface, or even change the person on call through their On Call Central voicemail box using a dial-by-name directory.
5. Cost. Medical answering services bill based on minutes used. Minutes in excess of the allotment are billed at a significantly higher rate. The result is that cost can vary significantly from months to month; we have, in fact, seen bills that vary by a factor of 2-3X based on only minimal incremental usage. On Call Central offers a fixed rate structure based on the number of providers who take call. Your bill is the same each month.
6. Documentation. Studies show that only 30% of patient phone calls are documented. On Call Central automatically time stamps all incoming voicemails and return calls. Additionally, we archive all patient voicemail, and allow providers to attach audio and written notes to patient communications. The documentation process through On Call Central is far superior to a live medical answering service, and it helps protect your practice from frivolous medical malpractice claims.
7. Caller ID Block. If you’ve ever had a patient call you on your cell phone at 3AM, you know the value of caller ID block. When you return a call through On Call Central we display the caller ID number of your choice (e.g. your office number), not your personal contact information. Most medical answering services do not connect you directly to callers, and those that do usually bill you for the service.
8. Automated Backups and Reminders. If you do not listen to a patient message within a specified amount of time, On Call Central can automatically send you a reminder, or notify a backup provider. No medical answering service can respond in a rules-based manner to remind providers and escalate communications in instances where a message in unheard.
9. Call Recording. On Call Central makes it easy to record and archive live patient calls. If call recording is enabled, callers are automatically notified, making the recording compliant with laws in all 50 states.
10. Device Elimination. Since On Call Central works with cell phones, pagers and landlines, you can eliminate any unnecessary or redundant devices. Many medical answering services are unable to send notification via cell phone text message, meaning that you often have to carry around an extra device.

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:

1. 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.
2. 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.
3. 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.

Click here to view the embedded video.

Anchorage, AK (PRWEB) March 30, 2009 — Acumantra Solutions, Inc., a leading developer of web-based software solutions, today announced that it has finalized functionality within its On Call Central medical answering service (http://www.oncallcentral.com) that helps medical providers get paid for phone calls that are deemed billable according to established codes, including 99441, 99442 and 99443, within the American Medical Association’s (AMA) CPT manual.

Telemedicine, especially in the fields of pediatrics, OB/GYN, psychiatry and primary care is not only time consuming for the provider, it also requires medical assessment and treatment recommendations. As a result, expenses and medical liability risk are incurred by providers and practices. Yet, despite the time, risk and costs associated with telephone care, most medical providers don’t have a system in place to document telemedicine interactions and bill patients or third-party payors for this type of care.

With On Call Central, medical providers now have an easy and cost effective method to flag potentially-billable telemedicine calls, document and time-stamp all interactions and optionally record related events, which provides a solid foundation for incorporating billable telephone care into an existing practice.

The benefits of establishing billable telemedicine protocols are numerous. For the medical provider, this creates a new and valid revenue stream while reducing patient abuse of after-hours calls. For the patient, the option to seek telephone treatment for conditions that don’t require face-to-face care is a tremendous convenience, especially among busy professionals and families with small children. Call types typically designated as billable include non-urgent after-hours calls, prescription refills and medical consultations with established patients.

“The concept of billing for certain provider-patient phone calls represents a paradigm shift in the management of telemedicine,” said Acumantra President and CEO, Sidney VanNess, Ph.D. “The AMA and American Academy of Pediatrics recognize telephone care as a legitimate and billable service. Third-party payors have begun establishing processing standards to reimburse providers for telephone-related CPT codes. And On Call Central gives providers a practical solution to identify and document potentially billable events.”

Physicians, practice managers and other health professionals interested in establishing billable telemedicine protocols or learning more about how On Call Central helps them get paid for telephone care can visit www.OnCallCentral.com or call 1-888-400-2514.

ABOUT ACUMANTRA SOLUTIONS AND ON CALL CENTRAL

Acumantra Solutions, Inc. is a privately-held software company focused on the development of software as a service applications (SaaS) for healthcare and small business markets. Thousands of people use Acumantra’s services every day to improve business process efficiency and generate a direct positive impact to their bottom line.

With the release of On Call Central, Acumantra has created a more efficient solution that replaces a medical provider’s traditional medical answering service. On Call Central is a web-based call management system that tracks, routes and archives patient calls, provider responses and post-call patient directives. It uses the latest technology to eliminate communication breakdowns and improve patient care, while protecting provicders from the risk associated with after-hours calls. For more information about On Call Central, contact Sidney VanNess, Ph.D.; 888-400-2514; info (at) oncallcentral (dot) com; www.oncallcentral.com.

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Contact Information
Sidney VanNess
Acumantra Solutions

http://www.oncallcentral.com

888-400-2514