Analysis of our data on closed claims shows that communication errors are one of the most common causes of adverse patient events in the office. We have found that communicating with telephone counseling and triage, a critical part of overall patient care and management, is a significant area of responsibility.
Telephone triage is the process of managing a patient's call to the office to determine the urgency of the medical issue, the required response from the staff or provider, the appropriate location if the patient needs to be seen, and the appointment time.
Implementing an effective in-office telephone triage system can improve physician-patient communication, quality of service, patient satisfaction, and continuity of care. It can also promote optimal clinical outcomes and reduce emergency room (ED) visits, while ensuring the patient has timely access to the appropriate level of care.1
Please note that the telephone screening process is separate and distinct from the guidelines that practices must develop and implement for visits specifically referred to as telemedicine encounters. For more information on this topic, see our article “7 tips for telemedicine.“
Address screening risks
However, telephone triage has inherent risks, as it requires an accurate assessment of the patient's concerns without the benefit of an in-person visit. For this reason, allow only licensed professionals with adequate training to screen patients over the telephone.
Define required qualifications and training in job descriptions for licensed personnel performing telephone screening. Provide written records for non-licensed employees who answer calls first. Include examples of specific questions to ask the caller and suggested responses to minor issues. Describe the types of calls that require an office visit, transfer to licensed provider for further evaluation, or direction to call 911 for immediate emergency response. Office staff should have clear guidance and repeated simulation training in situations where 911 must be called for immediate emergency assistance.
Explain to your patients that not all problems can be resolved over the phone and that the clinic decides whether a patient should be seen in person. If a patient or other interlocutor appears overly anxious or dissatisfied with the telephone consultation, or if the patient feels that the situation is urgent and requires immediate and more thorough attention, schedule an in-person consultation.
For emergency calls, instruct patients to dial 911 in situations such as (but not limited to) allergic reaction, abdominal or chest pain, eye injury or blurred vision, head injury, burns, active bleeding, loss of consciousness, seizure, signs or symptoms of infection, fever lasting more than 48 hours, early onset of labor, dressings that are too tight, symptoms of a stroke or difficulty breathing and/or wheezing. If the patient is unable to dial 911, one worker should keep the patient on the phone while another worker calls 911. This ensures a smooth and seamless transition to the next level of emergency service.
Physician practices have several options for establishing triage services and physician consultation protocols within their practices and medical specialties. Commercially available sources for screening protocols and service implementations include artificial intelligence using screening algorithms, EHR systems, professional societies, medical associations, commercial products, and contracted services.
- sorting algorithmsIt can help authorized clinical staff seeing patients and documenting phone calls. The responsible provider should review all phone selection decisions before they are used in practice. If a patient needs to be seen in the emergency department, the provider should contact the emergency department with a suspected diagnosis, a description of the symptoms, and information the office received during the call.
- Clinical Decision Support Systems(CDSS), a type of digitized tool, helps in clinical decision making. According to theOffice of the National Coordinator for Health Information Technologies:2
- Clinical Decision Support (CDS) provides physicians, staff, patients or others with information and insights specific to each person that is intelligently filtered or presented at appropriate times to improve health and the delivery of healthcare. CDS includes a variety of tools to improve decision-making in the clinical workflow. These tools include computerized alerts and reminders for caregivers and patients; clinical guidelines; state-specific order sets; focused reports and summaries of patient data; documentation templates; diagnostic support; and contextual reference information, among other tools.
- Please note that when using a CDSS, the vendor assessment may not exactly match the CDSS guidelines. In these circumstances, providers should document their rationale for clinical decisions.
- Telephone consultation minutesThey are used in outpatient practices to ensure consistency in information collected, recommendations made, and documentation of telephone interactions between patients and physicians. Consultation protocols help clinical staff decide where and when patients should access treatment. The logs may also contain notices about when it may not be appropriate to receive further guidance over the phone. For example, several protocols address common newborn issues such as cradle cap, circumcision care, and umbilical cord issues. The record may include the warning: "Use extreme caution when evaluating infants. Any suspicion of illness indicates that a face-to-face examination is warranted."
- Telephone consultation protocols should not lead to medical diagnoses. This restriction must be made clear to all employees and any patients who call.When using published protocols, providers should review and adapt the protocols to meet the specific needs of the practice and ensure that the protocols conform to accepted standards of care and authoritative sources.It is important to ensure that licensed clinical personnel who provide telephone counseling comply with state practice laws and have specific training, experience, and competency in telephone assessment techniques.
- Unlicensed personnel should never be authorized to conduct telephone assessments or provide telephone counseling. According to Don Basala, JD, MBA, Executive Director and Internal Counsel for the American Association of Physician Assistants (AAMA), “I define triage as a process of communicating with a patient (or patient representative) that requires the patient to contact healthcare professionals to establish independent clinical judgment and/or make clinical assessments or evaluations. It is my legal position that medical assistants should not be delegated to triage (as I define the term)."3
- Non-compliance with scope-of-practice requirements by non-clinical staff is a common medical malpractice liability issue in provider offices. To minimize your liability, implement appropriate job descriptions for all categories of office workers, train your employees, document your training, and do not allow employees to perform outside their area of responsibility.
- Hired screening serviceson the market are also an option for medical practices. Use accredited services that hire only licensed medical personnel and follow protocols consistent with the medical specialty's standard of care. Providers should review call logs regularly, as the practice provider is responsible for the instructions the service provides to its patients.
Telephone inquiry document
Carefully document all information related to the doctor's telephone appointment and follow up with the patient. For a claim arising from triage or telephone counseling, an undocumented interaction may result in a situation where the patient's word is against the word of a staff member or provider. The plaintiff's attorney will be quick to point out the old adage, "If it's not recorded, it never happened."
A request for advice may seem insignificant at this point, but an adverse event could occur if the patient does not follow the advice. Documenting patient instructions is critical to defending against later claims. Use theteaching method("Replay") to confirm that the patient received the message correctly and to document the patient's understanding. Regardless of when or where the contact occurs, record all telephone interactions immediately in the patient's record. Don't forget to include after-hours calls as well. It is important to have a system in place to ensure that all clinical calls received outside of business hours are recorded in the medical record.
Patient Safety Strategies
The provider is ultimately responsible for the telephone triage and medical consultation with the patient. Implement the following strategies to mitigate the risk:
- Implement written policies and protocols for clinic and office staff to follow when screening calls and providing advice. Conduct regular chart audits to ensure policies and protocols are being followed. Review the policy annually and adjust as needed.
- Educate agents on what questions to ask the caller and when to immediately transfer a call to the provider. The provider then knows that the patient has an urgent or urgent need when he or she is called on a call.
- Instruct staff to follow counseling protocols and contact the provider first if you have any concerns about appropriate guidance or counseling. Failure to do so could be considered practicing medicine and practicing beyond the employee's scope of work.
- Encourage staff to transfer calls directly to the provider when a patient calls a second time with a complaint that the previous telephone consultation failed to resolve.
- Request face-to-face assistance when the patient calls for the third time with an unresolved complaint in the previous telephone consultation.
- Document all calls with medical information or advice. Documentation should include date, time, patient's name, caller's name (and relationship to the patient), complaints, concerns, questions, and advice given. Use follow-up training with documentation that confirms patient understanding.
- Document critical negative information that helped determine the advice given. Examples: "The mother said that the child did not have a fever, lethargy or stiff neck" and "The mother said that the child had a good appetite and was taking fluids".
- Document reasons for deviations from written protocols.
- End all calls, instructing the patient when to call again or seek emergency services if symptoms worsen or persist.
To learn more about how to communicate effectively, read our article “Telephone communications for health professionals: safety strategies.” For guidance and assistance with patient safety or risk management issues, contact the Department of Patient Safety and Risk Management at(800) 421-2368ÖBy email.
- Lake R, Georgiou A, Li J, et al. The quality, safety and governance of telephone counseling and screening services: an overview of evidence from systematic reviews.Health Service BMC Res.. August 30, 2017; 17(1): 614. doi: 10.1186/s12913-017-2564-x
- Office of the National Coordinator for Health Information Technologies. Clinical decision support.SaludIT.gov
- Basala DA. The role of medical assistants in remote physiological monitoring services.CMA today. 2020 March/April: 6-7.http://www.aama-ntl.org/docs/default-source/other/cmatoday-ma-2020-pa
The guidelines suggested here are not rules, do not constitute legal advice, and do not guarantee a successful outcome. The final determination as to the adequacy of treatment must be made by each healthcare provider, taking into account the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which care is provided.