Protocol Guidelines versus Algorithms:
Critical Distinctions for your Clinical Call Center

By Deborah Lonzer, MD

April/May 2007

Call centers have become the best and most utilized way that we deal with patient concerns outside of - and sometimes during - office hours.  When comprehensive clinical content is combined with nursing expertise and experience, call centers using clinical guidelines can be the best opportunity for patients to get consistent quality care around the clock. 

Effective clinical call centers are an extension of the physician's office in that they provide quality advice in a personalized manner that is well-communicated to both the patient and to the primary provider.  The advice is delivered in a timely manner so that appropriate follow-up is assured.  As we decide what kind of telephone care is best for our practice, let's consider what kind of medical care we think is appropriate in the office setting and then extrapolate that to the telephone.  Let's contemplate some scenarios:

Scenario A: You just walked into your doctor's office, you're ill, and you're worried.  She says to you, "What seems to be the problem?" 

"My chest hurts."

 Never looking up at your face, she follows with a rapid-fire list of questions.  She requests that you reply only with yes or no and doesn't allow you to expand your concerns and tell your story.  She institutes a treatment plan for you, and while you feel some fear through the process, you get better. 

Would you feel well cared for?  Would you go back to her?

Scenario B: Your son's abdomen hurts.  He has no other symptoms.  You take him to his pediatrician who checks his abdomen.  After asking you some yes or no questions, he determines that there is nothing high risk about your son's situation and sends him home to drink some fluids and watch his diet.  In the middle of the night, your son's temperature is 103 and he feels awful - but it can't be anything bad or your pediatrician would've found it.  Or would he?  Maybe the outbreak of strep at your son's daycare was an important historical fact - but it never entered into your doctor's line of questioning, and you didn't see a connection at the time so your pediatrician was not aware of it.

Scenario C: You feel ill and make an appointment with your physician.  You arrive at her office and are met with a computer terminal.  You sign into the computer and after your name you are asked to "state your diagnosis."  You are frightened and now confused.  You don't know exactly what's wrong, but you know you don't feel right.  How can you be sure you're entering the most accurate diagnosis?  You would feel so much better if you could just tell them how you feel.

Obviously these are simplifications to make a point.  Life is not simple.  Medical illness is not simple.  Diagnosing and treating patients is not simple. 

Today's medically savvy society is more involved in their healthcare than ever before.  Patients are better able to help us care for them, but they also have higher expectations from their caregivers and their medical resources.  We need to live up to their expectations.  Medicine remains an art form within a scientific realm, and most of us select our providers based on a variety of parameters including personality, experience, expertise, and track record.  Therefore, it is logical our after-hours caregivers should be selected with the same stringent requirements.

When making a medical diagnosis, the history is more important than even the physical exam in most cases.  This affords call center nurses an important opportunity to provide symptom-based triage to determine a disposition of care without seeing the patient - but it must be done carefully through experienced caregivers.  Recent research (Procter & Gamble's Patient Preferences and Perceptions) shows that if we allow patients to tell their medical stories unencumbered by our own prejudices, they are happier with their interactions and more likely to listen to, trust, and follow the advice they are given. 

So how can we best setup a call center that allows patients to tell their stories, allows us to gather accurate histories, and allows us to deliver state-of-the-art medical information?  There are two mainstays of clinical call centers; the algorithm and the guideline. 

Algorithms are ‘if...then' plans.  They are well-suited to computer programs and allow for little individual input from the medical professionals who use them.  While they have utility, when something doesn't fit perfectly into an algorithm, there may be confusion, leaving room for error.

Guidelines are open-ended; they are not loose conversations but are supported by the substantive backing of protocols that guide them.  They are a give-and-take dialogue between the patient and the medical professional using them.  They create structure for the conversation.   They provide a comprehensive list of supporting medical criteria that helps the experienced medical professional to prompt the caller to fill in the unique details of their situation. 

Guidelines must be held to high standards in order to be effective. They must be based on the most current and up-to date medical information available and reviewed yearly.  They must be evidence-based in their recommendations with outcomes reviewed regularly.  They must be implemented by a well-trained and experienced cadre of medical professionals whose knowledge makes them more effective than mere words on paper.

The guidelines utilized by the Cleveland Clinic are evidence-based protocols developed by internationally respected physicians.  They have been proven in Cleveland Clinic's award-winning Nurse On Call clinical call center, which has safely triaged over 7 million clinical calls over fifteen years.  They are reviewed annually by over 200 medical professionals including pediatrics, family practice, and internal medicine.  They are executed by a well-trained, experienced group of registered nurses.  

Why Guidelines?

• Guideline protocols are structured, founded on the principles of emergency medicine, allowing RNs to screen symptoms using clinical judgment.

• Guideline protocols are evidence-based with outcomes reviewed regularly.

• Guidelines enable nurses to rapidly assess patients including their individual variability.

• Rather than nurses mechanically following a decision-tree to recommend care, patients benefit from the knowledge and expertise of an experienced medical professional.

• Patients benefit from a care plan thoughtfully tailored for them.

• Patients benefit from greater depth of symptom assessment for improved quality of care.

Simply stated, guideline protocols provide a greater opportunity to apply the expertise of the caregiver and the accumulated knowledge of evidence-based outcomes to the specific clinical needs of the individual patient.  Thoughtfully tailored caregiver expertise with applied evidence-based outcomes can mean better patient care.

Dr. Deborah Lonzer is Interim Chair, Department of Regional Pediatrics and Medical Director, Regional Health Affairs.  She is a practicing pediatrician who has experience with both algorithm and guideline protocols during fifteen years of experience, including both private practice and multi-specialty group practice settings.  Dr. Lonzer can be reached at lonzerd1@ccf.org or 800-553-5057.  Cleveland Clinic Guideline Protocols are provided in Sharp Focus® and EchoAccess™ software solutions from HealthLine Systems' Inc.