By Christopher Guadagnino, Ph.D.

Published July 1998

• React to this article in the Discussion Forum.

PND: Can you describe the Blues on Call Program?

BW: The program, as defined by Highmark Blue Cross Blue Shield, uses tools that our company has developed, one of which is a nurse-based, complaint-specific triage system. It allows people to call and speak to a registered nurse who asks a series of physician-written questions to try to help the person calling to decide what the right timing and response is for the symptom that’s bothering them: Do they need to hang up and call 911? Do they need to make an appointment to see their physician? Is self-care with watchful waiting appropriate? Another tool that we provide is the ability to reflect with computer systems the kinds of things that are done in the offices of individual members of a network. A third tool allows us to reflect practice guidelines that our clients have developed that would indicate when it would be appropriate within a network to make a referral to a specialist. Provider groups and integrated delivery systems make up about 10 percent of our clients, while the rest are health plans, Medicaid, Medicare, employers and government.

PND: How was the system developed?

BW: The triage algorithms were developed by a panel of physician experts who wrote a set of chief complaint-specific questions that would replicate the questions they’d want to ask if they were talking to the patient to try to figure out what to do with them. Those questions were then reviewed by a national panel of physicians, and they’ve been reviewed locally by physicians in over 120 clients that our company has. We started using the algorithm system in 1993. We work with each individual client to find out what kind of referral rules they wish to have reflected within the network so that we can replicate them.

PND: How are the algorithms updated?

BW: There are full-time physicians who work for us to oversee that process, and an advisory board of outside physicians that work with them to make changes in the clinical content on a regular basis. They take comments that come in from our clients, our patients, physicians and others who work with us. We can reflect local practice standards and have those be the guidelines that are used when patients from those geographic areas are speaking to our nurses.

CV: The whole concept of algorithms has been extensively reviewed and discussed by our Keystone Health Plan West Quality Improvement Committee, which is made up of local practicing physicians. They’ve had the first opportunity to look at this and are comfortable with the general concept of algorithms. We are in the process of putting together a separate committee of five specialist and primary care physicians that will be responsible for reviewing our utilization management criteria to make sure that they are clinically sound and up-to-date.

PND: How are the nurses in the call program trained?

BW: They go through an interviewing and qualifications process before they are selected to begin training. They have to have been in clinical practice for five years, and that practice has to involve patients, so they are not nurses who work in a research lab. They have to go through a series of skills interviews to show that they have the problem-solving qualities that we want. The first week of the training program is classroom. The second and third weeks are a combination of classroom and proctored on-the-phone experience using the system and talking to patients with a nurse instructor on the phone working with them. In the forth week, they are taking calls again with a nurse instructor, but one who is doing more listening than talking. At the end of those four weeks, most of the candidates are able to move to proctored practice as nurses in our care centers. From that point on, the intensity of oversight of each nurse is really a function of their performance. There’s ongoing proficiency training and monitoring.

PND: How can a nurse in a remote location give medical advice to patients they never see and for whom they have no medical history documentation?

CV: At night, it’s a rare physician who has medical records when they’re getting a call. Usually, the physician will not know the patient that well, considering that there are multiple doctors taking calls for a group and sometimes cross-covering for other groups. We believe that this system does afford the opportunity to give more information and does not detract from the patient-doctor relationship. This system still promotes the idea that the patient is going to follow-up with their physician.

We’re dealing more and more with patients in western Pennsylvania who are turning to hospital phone-in services, to various consumer groups that provide information through telephone systems, and we have a number of members who tell us they are using Internet services and other advocacy groups. If physicians don’t think that their patients are turning to those sources of information, as well as to the more traditional next-door neighbor for advice, then I think they’re not being realistic about where patients are getting their information. We believe we’ve got a program that keeps that information in a clean, clinically appropriate system and keeps the physicians, particularly the primary care physicians, within the system so that patients go back to them. I think that’s a better response to what’s going on out in the general community, and that physicians will be pleased, considering what are the alternatives.

BW: Our service does not make diagnoses, but rules out diagnoses of medical conditions that can be serious. What we do is risk assessment to get people to the right kind of care at the right time. Our nurses answer the phone within 30 to 40 seconds of the ring, 85 percent of the time, and speak to patients for 6 to 12 minutes at a time. We’ve got excellent outcomes data to show that, in fact, we’re not missing things and we are reflecting recommendations that coincide with those of physicians.

PND: How will you determine which physicians get referrals through this program?

CV: All physicians in our network have received a clinical backgrounder, an extensive questionnaire that asks what services they wish to perform within their office and their general practice. It covers medical conditions ranging from those for which they wish to see the patient first, make a decision, then send the patient on, to conditions where the physician takes care of the entire problem, including any procedural therapies that need to be performed. If a specialist is recommended, the patient will be given a range of specialists within the Keystone Health Plan West network to choose from. We narrow the choice a little bit based on geographical area. At this time, we don’t have a mechanism to make a referral to a specific physician directed by the primary care physician. We are looking at trying to put that into place in the near future. We recognize that is a request that many of our primary care physicians have had. Access Health says it is trying to incorporate that into the software.

BW: From a historical perspective, this is how calls to Access health nurses end up being sorted: 41 percent of callers are instructed in self-care, 30 percent are given a time-specific recommendation—based on symptoms—to speak to a physician, 17 percent are given a time-specific recommendation to make a physician appointment, 8 percent are advised to visit an Urgent Clinic, 3 percent are advised to visit an emergency department and 1 percent are advised to call an ambulance. What’s interesting is that, of all the people who call us, 85 percent end up doing something different than they said they would have done had this service not been available. All of the information from the call is put into a computer database, which generates a written record that will go to the primary care provider.

PND: Is the system voluntary?

CV: At this time, yes. The patient can use the system or choose not to use the system. None of our benefit plans mandate it’s use. What is different about our program, compared to some other demand management programs across the country, is that this is not a system in where the patient must follow the care plan outlined by the nurse. The patient is given advice and choices. If the patient gets a referral by Blues on Call, then it would automatically be paid under the benefits described for that member.

It is also voluntary for physicians, who can choose not to participate. We’re trying to encourage as many physicians as possible to work with the program at the beginning. For those physicians who stay out for a while, I think they’ll quickly see that it has benefits.

BW: What we’re trying to reflect is what happens, I hope, in my office when a patient calls up and asks to see me to have a mole removed. What I don’t want is for my office staff to just make the appointment. What I would like them to do is to say that I don’t do that sort of thing, but will see them and perhaps refer them to another physician. We’re trying to make the system more reflective of normal practice, not of some kind of rigid Praetorian guard system.

PND: Is there any consideration of making the program mandatory for physicians, particularly in the least expensive of Highmark’s plans?

CV: Not at this time. It’s not part of their contract. We have not discussed making it mandatory. I don’t see a great advantage to that, anyway. If something works well and is a benefit to patients, the physicians will take it. If it’s not working out and we cannot show evidence that it’s a benefit, then we’ll work on trying to make it better.

BW: None of our tools are used by any of our clients in a mandatory way. We strongly believe that if we build good tools, people will use them because they make their job and their life easier. And that’s what’s happened.

PND: What is the advantage to Highmark of using this system?

CV: Part of it is to respond to the growing consumerism that we’re finding among our own members. If the system works the way we hope it will, it will satisfy patients’ desire to get more information and have more control over the decisions being made about their health care, and it will provide physicians with more information about what’s going on with their patients, and do it in a more timely fashion. This program was not designed to reduce utilization. It was designed to help promote appropriate utilization. In some cases, we think there will be more utilization by individual patients, but appropriately so, and overall the program will promote better care.

PND: Who is liable if the advice given by the nurse on the phone leads to an adverse outcome?

BW: We will indemnify Highmark Blue Cross Blue Shield or its network members if the adverse outcome is found to be a result of an inappropriate action by someone who worked for us, or if the clinical tools that they were using were clinically inappropriate. Two years ago, the liability insurance premium for one of our four call centers, which had over 100 nurses working in it, was less than the malpractice insurance for an ob/gyn physician in Washington D.C.