Barry W. WolcottAssociate Professor Military and Emergency Medicine

Uniformed Services University, Bethesda, MDand

Chief Medical Officer, Expert-24 LTD

barry@expert-24.com

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Can Smart Phones be “Smart Enough” to Replace RNs in Call Centers?

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SICK WHAT TO DO

A common dilemma

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Seek help Play the odds

Conventional options

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Call, and … … Ask A Nurse

You could …

• Actually Answer Your Question: What to Do• Convenient• Proven safe• No Out-of-Pocket Cost

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… but, that is so “90’s”

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You have on-line options …

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... but, at best, you get …

A list of possible causes:

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… and lots of stuff to read …

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… but, no real guidance!

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An on-line tool must …

• Be web and mobile device enabled;• Utilize robust branch-chained decision

support tools mimicking the complexity of tools used by RNs in Call Centers;

• Provide a recommendation as to the medically most appropriate “next step.”

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Broad Deep

…while being simultaneously …

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Rare Common

… and considering causes …

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Watchful waiting Evaluation now

… ultimately, giving real guidance

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Low Back Pain Questions:

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In US: In UK:

Current sources

Primary driver currently is to reduce call center overhead while retaining acceptable ring-to-answer time … that driver is morphing into a perceived need to be “mobile accessible.”

Yes, about 35% of the time!

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Can Smart Phones be “Smart Enough” to Replace RNs in Call Centers?

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QUESTIONS

Telephone-Based Nurse Triage Call Centers in the US

• Began in late 1980’s … now ubiquitous;• Provide millions of caller each year with advice as to

“what to do next” … from “Call 911” to “Self Care and Watchful Waiting;”

• Operated/Contracted for by Plans, Payers, Employers to reduce:– Medically unproductive ED/Acute care visits;– Absenteeism;– Out-of-pocket employee costs;

• Very popular and accepted.

Early Concerns Easily Overcome

• Advice Quality: Advice mirrors that of equally informed physicians

• User Acceptance: 90% subsequently report they followed the advice provided;

• Liability: No liability verdicts for properly operated systems;

• Cost Effectiveness: Consistently > 3:1 ROI

How Is It Done

• RNs telephone interview and subsequent recommendations guided by decision support software that considers:– What conditions could cause that symptoms?– How frequently is each of those conditions among callers of this age

and gender (pre-test probability)? – Are there RN-gatherable Q-A pairs that combine to lower the pre-

test probability sufficiently to “clinically exclude” each condition?– What would be the best advice for each condition, if it were present?– How great are the effects of a delay in diagnostic evaluation?– What is the “worse” condition that cannot be “clinically excluded?”

Between Scylla and Charybdis

• Call Center Costs: Primarily determined by a contractual requirement to meet a client-determined “ring-to-answer-time” 95% of the time;

• Effectiveness: Lengthening the R-T-A time results in:– More hang-ups and follow-on ED/Urgent care visits;– Caller ill-will– Increased likelihood that evaluation of a serious

condition will be delayed.

Reality Check

• The shorter the ring-to-answer-time, the larger the number of nurses that must be on duty at any moment … however, much of the available nurse time will be required only for high call volume periods of the shift;

• The cost-per-call answered rises with each reduction in ring-to-answer time … and rises dramatically with incremental lowering below 2 minutes;

• Achieving ring-to-answer-times of 30 seconds (a common desired performance level) produces costs-per-call in the range of $30-$45;

• Substituting a mobile application that succeeds in mimicking Call Center RN performance would have a dramatic effect on costs … even if only used 30% of users.

Can Symptom Assessment Be Done Safely “On-Line?”

• Yes, but … Not using the “symptom checkers” currently available on major medical information web-sites … these are “toys, not tools;”

• On-Line Success Stories: – In The US:

• Mayo Clinic• McKesson

– In the UK:• http://www.nhsdirect.nhs.uk/en/CheckSymptoms• http://health.expert-24.com/demo/symptomAssessment.aspx?m=TlNb

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