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Articles from AnswerStat

Telephone Triage for the Medical Call Center

By Peter Lyle DeHaan, Ph.D.

Of all the exciting advances in medicine, there is one that falls outside the traditional scope new drugs, innovative procedures, or revealing research. This development is in the application of telephone technology to facilitate the provision of healthcare. Lumped into the broad category called telemedicine or telehealth, the telephone is cost-effectively improving patient care while increasing patient satisfaction. The application of technology to cut costs and improve quality in any industry is noteworthy; in medicine, it is critical.

One of the most exciting developments in telemedicine is telephone or nurse triage. The history of telephone triage dates back three decades. For Dr. Barton Schmitt, arguably the father of telephone triage, it was born out of the practical necessity of ensuring consistency and accuracy among those who interacted over the phone with parents concerned about a child’s well-being. His initial telephone protocols have been refined, expanded, and validated for the past 30 years. More than 400 call centers are using computerized versions of his work and an estimated 10,000 pediatric offices refer to the printed version. Others have independently developed similar protocols.

Telephone triage will be a reoccurring theme in AnswerStat, as we believe it is an important development, not only for medical related call centers, but also for healthcare as a whole. Our goal in this issue is to introduce the subject and provide some initial resources. Look for more information and articles in upcoming issues.

Telephone Triage Call Centers: There are several call centers that provide telephone triage on an outsource basis, or for a fee, to hospitals, clients, individual practices, and medical answering services. View our current list.

Telephone Triage Vendors: Lastly, here is a list of vendors who have integrated telephone triage protocols into call center software.

Books on Telephone Triage: As a primer for learning more about telephone triage, you might want to refer to some of the many books available on the subject. Here is a list of some of them (let us know your favorites and we will add them to our list):

  • Pediatric Telephone Advice by Barton D. Schmitt (Spiral-bound)
  • Pediatric Telephone Protocols: Office Version by American Academy of Pediatrics, by Barton D. Schmitt
  • Quick Reference to Triage by Valerie G. A. Grossman, et al.
  • Telephone Health Assessment by Sandra M. Simonsen
  • Telephone Medicine: Triage and Training: A Handbook for Primary Care Health Professionals by Harvey R. Katz, Harvey P. Katz
  • Telephone Triage: Theory, Practice, and Protocol Development by Sheila Q. Wheeler, Judith Windt
  • Telephone Triage for Obstetrics and Gynecology by Vicki E. Long, Patricia C. McMullen
  • Telephone Triage of the Obstetric Patient by Deborah E. Swenson
  • Telephone Triage Protocols for Adult and School Age Populations with Women’s Health and Infant/Child Protocols by Sheila Wheeler, RN, MS
  • Tele-Nurse by Marijo Baird, Sandi Lafferty

Additional Resources: TeleTriage Systems: Sheila Wheeler;;

Peter DeHaan is the publisher and editor-in-chief of AnswerStat magazine and a passionate wordsmith. Connect with him on his personal blogs, social media sites, and newsletter, all accessible from

[From the Fall 2003 issue of AnswerStat magazine]

Vendor Spotlight: 1Call, a Division of Amtelco

Providing the one complete communications system designed to bring it all together

1Call Division of Amtelco provides call center services, PC-based PBX consoles, soft agent, secure communications, emergency notification (HICS), event notification, appointment reminders, and communication systems for healthcare organizations.The 1Call Division of Amtelco, formed in 1997, is dedicated to serving the unique call center and communication needs of healthcare organizations. 1Call focuses on delivering tools to allow patients, physicians, and staff to communicate together as a well-synchronized team.

Exceeding Customers’ Needs: Every patient deserves the best care possible. 1Call’s goal is to provide healthcare organizations with the tools to efficiently handle caller’s requests with a single phone call, saving time, eliminating confusion, and providing patients with the best service possible.

By continuing to meet and exceed customers’ needs, the list of 1Call customers continues to grow. 1Call has hundreds of healthcare customers throughout the US and Canada, both large and small. A snapshot of 1Call customers include: Allina Health System, Anmed Health Medical Center, Bassett Healthcare, Bethesda Healthcare, Billings Clinic, Fairview Health System, Hennepin County Medical Center, Queen Elizabeth II Health Sciences Centre, Sherman Hospital, St. Francis Hospital, University of Augusta Health Care System, University of Nebraska Medical Center, and University of Washington Medical Center.

Innovation: 1Call designs high-performance software applications to offer robust systems that provide hospital-wide communications. Frequent software releases give customers access to the newest features and technology. The 1Call systems furnish seamless integrations with existing legacy IT and PBX networks to save costs and bring information together in a single location, as well as including VoIP and SIP integrations.

The 1Call Modules Include:

  • Call Center Systems: The Infinity system is used by hundreds of hospitals and healthcare organizations. Infinity can be designed for small or large organizations with as few as three to as many as 200 agent/operator stations.
  • PC-Based ACD Agent Stations: Infinity agent/operator stations allow users to make the most of triage, scheduling, physician referral, appointment taking, and other IS programs by adding essential functionality, including ACD call routing, call recording, statistics and reporting, desktop access to all IS modules, screen-based speed dialing, on-call schedules, and Web-based directories.
  • Flexible Call Scripting: Script calls for operators for any hospital-wide application, including patient-to-physician referral, physician-to-physician referral, appointment taking, and class registration.
  • On-Call Scheduling: Allows physicians and staff members hospital-wide to enter their own on-call schedules; the information that operators see is always current.
  • Directories with Individual Contact Methods: Paging, text messaging/SMS, email, and however staff needs to receive communications.
  • Pro Show Appointment Reminders: Automates appointment reminders for patients to help keep physicians’ schedules full. Reminders are sent via email, cell phone, PDA, text-to-speech phone call, and IVR.
  • “Just Say It” Speech Recognition: Gives internal and external callers an easy way to reach the correct person or department when they “just say it.”
  • IVR: Uses Interactive Voice Response (IVR) to automate routine phone calls, such as appointment taking, appointment reminders, class registration, help desk, and physician referral.
  • Call Conferencing: Easily creates multi-party conferences, with or without operator assistance.
  • Voice Logger: Automatically records all calls with screen captures, giving the data needed to ensure accuracy and compliance.
  • Browser-based Applications: Provides convenient access to on-call schedules, directories, patient census, and paging.

Speeding Response Times: When every second counts, organizations need to respond quickly. 1Call’s Red Alert emergency and event notification system has proven to help organizations get personnel to the right place at the right time. Red Alert issues automated alerts by phone, mobile phone, SMS, email, pager, or other methods, ensuring that responders quickly receive alerts. Red Alert is ideal for use in every department for handling code calls, staff shortages, meeting reminders, contingency planning (JCAHO), emergencies (HICS), network outages, scheduled – or unscheduled – events, and weather emergencies.

Featuring 5-Star Service and Support: 1Call works closely with each healthcare and higher education organization and has a reputation for complete, professional system support, offering training, installation, and technical support staff on-call 24/7. 1Call’s 5-Star Service and Support is more than just a slogan; it’s included with every 1Call system:

  • An Informed Customer Care Group: Project managers and the innovation development team work with customers before, during, and long after the installation of 1Call equipment.
  • Experienced Trainers and Installers: Receive detailed training and a smooth installation to help streamline communications for the entire organization. Continuing education opportunities ensure customers are able to utilize the newest features.
  • Knowledgeable Field Engineers: Call or email for field engineering specialists to assist with technical questions.
  • On-Line Resource Library and Tech Helper: Available 24/7 for instant answers.
  • Healthcare Call Center User’s Group: The NAEO (National Amtelco Equipment Owners) group gives valuable support and a creative community for sharing ideas.

Early History: 1Call has a strong history in the telemessaging industry. Amtelco, the parent company of 1Call, was founded in 1976 to provide computer-based telemessaging solutions to the answering service and medical messaging industry. Bill Curtin, the founder of Amtelco, first received a telecommunications patent in 1951. Since then, Amtelco has added an additional 28 patents.

Amtelco Today: Under the leadership of Chairwoman of the Board, Eleanor Curtin, and President, Tom Curtin, Amtelco currently employs over 150 personnel in solutions development, customer care, field engineering, manufacturing, and administrative staff located at Amtelco’s main office in Wisconsin.

Amtelco also has twelve sales offices throughout the U.S. and Canada. In addition to the healthcare and higher education industries served by 1Call, the Amtelco TAS group handles the telephone answering service industry, and the Amtelco XDS group provides computer telephony boards to developers around the world.

The Future: 1Call is dedicated to continuing to provide healthcare and higher education organizations with the modules and features needed to offer more services while containing costs. By working closely with customers, 1Call will continue to develop innovative features and products.


  • 1954: Bill Curtin, Amtelco’s founder, receives a US patent on Telesignal, the first concentrator/identifier.
  • 1976: Amtelco is founded to develop, install, and service products in the commercial telephone answering service market.
  • 1977: Amtelco installs its first computer telephony integration (CTI) system named Video III.
  • 1983: Amtelco develops EVE (Electronic Video Exchange), the first paperless ACD and CTI product.
  • 1988: PC-MX, Amtelco’s first-generation PC-based ACD CTI product, is introduced. PC-MX is a patented product that featured paperless messaging and voice processing features.
  • 1993: The Infinity system is introduced. Infinity is the third-generation, PC-based CTI product. Evolving from the PC-MX system, the open architecture Infinity system allows users to take advantage of off-the-shelf PC technology.
  • 1997: Amtelco launches 1Call Division to develop products and service healthcare and higher education markets.
  • 1998: 1Call develops over 150 new features on the Infinity platform.
  • 1999: Infinity software version 5 is introduced.
  • 2000: The eCreator system is introduced, using scripts to simplify complex calls for appointment taking, class registration, and physician referral. Infinity Software Version 5.1 and Voice Logger are introduced.
  • 2001: 1Call offers eLink Hosted Services, and Infinity introduces eResponse, giving organizations an easy way to respond to email messages.
  • 2002: eCreator Software Version 2.0 is introduced, including IVR and appointment reminders. Infinity adds conference bridge.
  • 2003: 1Call introduces Red Alert emergency notification, “Just Say It” speech recognition, and Infinity software version 5.2.
  • 2004: Infinity IS (Intelligent Series) is introduced with Infinity software version 5.3. Infinity IS features innovative enhancements for messaging, on-call scheduling, directories, and dispatching. The Resource Library is also introduced, allowing customers to share Infinity, eCreator, and IVR scripts.
  • 2006: Infinity software version 5.4 is released, with Infinity IS enhancements. Red Alert adds mapping capabilities, making it easy to trigger alerts for specific areas.
  • 2007: 1Call introduces Discovery Forums, which are led by customers and give participants another way to network and share ideas.
  • 2008: 1Call introduces Infinity software version 5.5 with Infinity IS enhancements, the Infinity IS soft agent, and receives a patent for “A System and Method for Intelligent Script Swapping.”
  • 2009: 1Call introduces Synergy HL7, which instantly communicates HL7 data to the personnel who need it. Synergy HL7 is a performance improvement tool that provides advanced, automated notification technology. Red Alert adds ESRI® and Google mapping capabilities. 1Call receives a patent for “System and Method for Dynamically Creating Records” for IS scripting which creates a record in the CMI database

Contact 1Call at 800-356-9148,, or

[From the Fall 2003 issue of AnswerStat magazine]

Six Sigma Your Contact Center

By Dr. Jodie Monger

The contact center is one of your organization’s most valuable assets. Ninety percent of your callers base their image of your organization on their experience with your call center. The contact center is (or should be) the center of the corporate universe. Why, then, is so much time spent by managers justifying its existence? Too often, high-level executives do not understand the value of the contact center to the company’s brand image or its contribution to shareholder wealth. Education within your company is your responsibility. How do you gain the positive attention to move the contact center into the center of the universe?

Many companies have been or are beginning to use the Six Sigma methodology to improve quality throughout their organizations. The beginning, middle, and end of this cycle of the Six Sigma process is the voice of the customer. A logical place to look for such information is in the contact center. Where else can the green and black belts, who are responsible for driving continuous improvement in the Six Sigma system, find the pulse of the customer?

Six Sigma provides a framework to identify your customer critical-to-quality metrics that lead to customer satisfaction and quantify the cost of poor quality. When routine customer interactions are not handled in the customer-correct standardized way, it is a defect and customers will be dissatisfied. As you identify and correct defects, resources are saved and the savings can be reinvested back into your processes to continue to increase customer satisfaction and organizational income. The cycle is quite powerful and is a competitive advantage.

Herein lies an opportunity to leverage the contact center. Make a connection with your company’s master black belt to let him or her know that the contact center is a Six Sigma resource and that you have opportunities for Six Sigma projects as well. Next to a manufacturing line, there are no other functions in an organization where the operational data is more readily available than a contact center. The ability to measure aspects of the function is critical to the Six Sigma effort – define, measure, analyze, improve, and control.

A Six Sigma project team requires the voice of the customer to determine a need for a project and to then determine the success of a project. In our effort to provide the mechanism to measure the quality of service delivery, completely automated telephone surveys of real-time customer feedback has provided the needed measurement for many Six Sigma projects.

The automated surveys also provide the channel for additional projects focused on other organizational aspects by also implementing additional fully automated telephone surveys in parallel. This ability affords the contact center the right to claim its status as the focal point of the organization. The contact center can implement a Six Sigma project related to call resolution while also fielding surveys to measure satisfaction with the billing process and the product quality/repair process. Essentially, you should become the go-to group for customer opinion measurement.

Be prepared for a change. The ability to measure customer opinion with a sound, inexpensive option has catapulted the status of contact center teams within the organizational hierarchy finally giving credit where credit is long overdue.

Jodie Monger, PhD, is the President of Customer Relationship Metrics, L.C. Prior to joining Metrics, she was the founding Associate Director of Purdue University’s Center for Customer-Driven Quality. For more information about completely automated telephone surveys contact Jim Rembach at 336-288-8226 or or call their demo line at 866-537-8500.

[For more information about Six Sigma, see What is Six Sigma?]

[For many organizations Six Sigma is simply means a measure of quality that strives for near perfection. It is a disciplined, data-driven approach and methodology for eliminating defects (driving towards six standard deviations between the mean and the nearest specification limit) in any process. The statistical representation of Six Sigma describes quantitatively how a process is performing. To achieve Six Sigma, a process must not produce more than 3.4 defects per million opportunities. A Six Sigma defect is defined as anything outside of customer specifications.]

[From the Fall 2003 issue of AnswerStat magazine]

The Six Cardinal Rules of Customer Service

By Nancy Friedman

International Customer Service Week was October 6. That’s good, but we like to celebrate customer service all year long. Here are the Telephone Doctor’s “Six Cardinal Rules of Customer Service.” Any one of these tips will enhance your customer service reputation.

  1. People before paperwork: How many times have you stood and waited while someone tallied up a batch of figures or counted a pile of money? Then, only after they were done were you asked, “Now, how can I help you?” How many times have you waited while someone “fiddled” with something or wrote up a note, before he or she acknowledged you? Paper can wait. People should not. Paper won’t walk away, but the customer might. Drop what you’re doing and pay immediate attention to the customer.
  2. Don’t be too busy to be nice: In most interviews, managers and owners hear something like this from the applicant: “I love to be busy. If I’m not busy I get bored and unhappy.” Then we hire them and one of the first things we hear is the complaint, “Wow, I am so busy.” Well, being busy does not give you carte blanche to be rude. Let’s not be too busy to be nice. It’s not worth it.
  3. Rushing threatens customers: Whether it’s on the telephone or in person, avoid rushing people. Make each experience a great one. Remember, one word answers make you sound cold and unfriendly. Slow down. Stop rushing people. It threatens them.
  4. Don’t use military language on civilians: Simply put, company jargon should stay within your company. Mistakes and miscommunications thrive on company jargon. You’ll be far more familiar and comfortable with the terms and abbreviations than your customer will. Some companies seem to have words and abbreviations that would make the CIA green with envy. Use simple, easy to understand words with the customer. They’ll appreciate your thoughtfulness.
  5. Be friendly before you know who it is: Have you ever been a customer and been treated in a rather average, maybe even below average, manner? Later, when they realized you were a friend of the boss or someone other than an “average” customer, they brightened up? Why wait to be friendly? Why discriminate? If you’re friendly before you know who it is, you’ll make a good impression. When you’re friendly before you know who it is, you’re delivering the same great service to everyone. That’s the way it should be. Don’t discriminate.
  6. “There ya go,” is not “Thank you.” “Uh huh,” is not “You’re welcome.” Count for one day, how many times people forget to say, “Thank you,” and “You’re welcome,” to you. “There ya go,” just doesn’t hack it. When customers spend money, they want to hear a big smiling, “Thank you, we appreciate your business.” When we, as customers say, “Thank you,” we don’t want to be grunted at with the old, “Uh-huh.” Speak clearly. “You’re welcome,” is a wonderful phrase. Please use it more often, and don’t be a grunter. When your customer tells you, “Thank you,” give a great big smiling “You’re welcome,” right back at them.

Nancy Friedman is a keynote speaker at association conferences and corporate gatherings. She is also the author of four best selling books on Customer Service. Contact her at 314-291-1012 .

[From the Fall 2003 issue of AnswerStat magazine]

Legal Considerations of Voice Logging

Compiled by Peter DeHaan, Ph.D.

Legal issues regarding the recording of phone calls must be considered before embarking on voice logging. This varies on a state-by-state basis. Some states and countries require “one-party notification” in which only one of the two individuals needs to be made aware that the call is being recorded. This, of course, is most easily done by notifying the call center agents and staff.

This notice should be included in the employee handbook they receive when hired. By signing off on the handbook, it has been documented that employees have been duly notified that the recording will take place.

Check with a local attorney familiar with state employment law, as it may be advisable to have a separate sheet signed by each employee, which explicitly notifies him or her that calls will be recorded. (At least thirty-seven US States, the District of Columbia, the US Federal law, Canada, and England only require one-party notification. Note that there is some disagreement over the determination of the requirements for a few states.)

The other scenario requires that both parties be made aware that the call is being recorded; these are called “two-party notification” states. (Depending on the source, ten to thirteen US states fit this category.) This can be accomplished by playing a preamble recording on every call or inserting a periodic beep tone.

The preamble recording is common, but may prove to be a technical challenge to accomplish in a call center where multiple types of calls are taken and for various departments or clients. There is also the concern of how to respond to clients who object to an automated announcement before every one of their calls. Typical verbiage for the announcement or preamble recording is, “Thank you for calling ABC Clinic, your call may be monitored for training or quality assurance purposes.”

Alternately, many voice logging systems provide an optional beep tone. There are specific parameters to which this beep must adhere. According to VLR Communications, the beep tone needs to be a 1260 to 1540 Hertz tone, lasting 170 to 250 milliseconds, and broadcast for both sides to hear every twelve to fifteen seconds when recording is taking place.

The interesting part of this requirement is that both parties must be able to “hear” the beep tone; there is no measurable audio level specified. Therefore, it makes sense to set the beep level at a low volume, while still being audible to both parties. Still, many people find this beep tone to be disconcerting and distracting. Although call center agents typically grow accustomed to the beep tone, eventually tuning it out, this is not the case with callers, who generally find the ongoing beeping to be an annoying vexation. Callers may even discuss the beep tone or voice recording with the agents, thereby lengthening call time and decreasing the quality of service.

Several websites contain information about notification; unfortunately, they are not in complete agreement. This is shown in the chart below. Regardless of this information, be sure to consult a local attorney before recording any telephone calls.

Also, there are privacy concerns and issues. In general, one should take every possible precaution to avoid recording personal phone calls. A practical way of doing so is to only record conversations in the call center (and explicitly not in the breakroom or on any common area telephone) and to have an enforced policy against placing or receiving personal phone calls while in the call center.

These steps will help to ensure that personal phone calls are not inadvertently recorded and that privacy rights are not encroached. Again, obtain legal counsel before recording any phone calls. Voice logging is best used for quality assurance, training, self-evaluation, verification, and dispute resolution.

[For more information, see our Voice Logging feature article and Voice Logging Vendors.]

Peter DeHaan is the publisher and editor-in-chief of AnswerStat magazine and a passionate wordsmith. Connect with him on his personal blogs, social media sites, and newsletter, all accessible from

[From the Fall 2003 issue of AnswerStat magazine]

Dr. Barton Schmitt Interview: Telephone Triage Protocols

By Peter Lyle DeHaan, Ph.D.

One of the pioneers of telephone triage protocols is Dr.Barton Schmitt. His telephone triage clinical content for pediatrics is used by McKesson, LVM Systems, Epic, Intellicare, Fonemed, and United Health Care (Optum). Together that is over 400 call centers. The book form is used in an estimated 10,000 pediatric offices. With a 30 year history behind it, we recently asked him to share his story with readers. Here is what he had to say:

How has the triage protocols changed over the last 30 years?

They have become more complete and more comprehensive including lots of background information to help nurses learn this field. They have also become more experience-based (I know 10 times more now than I knew then), and more evidence-based, thanks to research on them and the ever-expanding medical literature.

How did you get started?  Why did you write the Telephone Triage Protocols?

I’ve always enjoyed the challenge of taking parent phone calls and trying to make the correct diagnosis without seeing the patient. In 1973, while I was Medical Director of the Urgent Care Center (UCC) for children at the University

By 1975, the collection of triage protocols had grown to 100. Graduates of our program who were going into practice began to ask for them and I provided them in binders. Over the course of a few years, I’d given away over 200 of these binders. By 1978, I’d expanded the collection to over 180 topics and tried to find a publisher. I submitted to the leading medical publishers. The book received unanimous rejection letters. The main reason they gave was that “it was heresy to suggest that nurses could (or should) ever triage medical calls.”

In 1980, the book Pediatric Telephone Advice was finally published by Little, Brown & Co. in Boston, who was just breaking into the medical publishing business. Within a matter of years, it was also published in French, Portuguese, and Japanese. It has continued to be a good seller and is going into its third edition. This book has remained a self-study guide for nurses or physicians in training.

In 1990, I wrote a streamlined (telegraphic) version for use by the advanced practice telephone triage nurses who worked in our call center at The Children’s Hospital (TCH) in Denver. The new book was called Pediatric Telephone Protocols. In 1994, I self-published this book because of the demand for it by call centers at other hospitals. I updated it yearly. In 2000, the American Academy of Pediatrics (AAP) picked up the publishing and distribution rights. The 10th edition will be released in early 2004. In 1994, I also started collaborating with NHES (National Health Enhancement Systems) to produce a software version of pediatric telephone triage. Because our call center was covering for over 120 pediatricians, we needed to improve efficiency. In 1999 I became software vendor neutral. In 2000, I collaborated with David Thompson, MD.

Why did you partner with David Thompson, MD, FACEP?

David and I share similar backgrounds, and therefore we find it very easy to work together. Working in the Emergency Department (ED), David is involved with direct patient triage on a daily basis. That’s required in a setting where you have 10 patients in different rooms and you need to prioritize exactly who you’re going to see next, who gets a procedure, who gets an x-ray, and who can safely wait. I worked in an emergency department for five years, and know how important it is to have razor-sharp decision-making. At the present time, David is on the American College of Emergency Physicians (ACEP) and Emergency Nurse Association (ENA) National Triage Task Force that’s attempting to standardize emergency department triage.

The advantage of us working together is that the adult triage protocols and the pediatric triage protocols share parallel layouts, dispositions, and logic. This makes it easy for the nurse in a full age range call center to move back and forth from pediatrics to women’s health to adult health to geriatric decision making. Nurses appreciate the seamless flow between protocols. Having two people responsible for keeping the protocols compatible is an attainable goal. We have developed over 100 rules that we follow closely to achieve and preserve clarity and consistency. David is my best critic. We spur each other on to producing a better triage product.

How important is feedback from others?

It’s the lifeblood of the fine-tuning process. I’ve been medical director of the Children’s Hospital After-Hours Call Center since its inception in 1988. It is the crucible in which I test my protocols. I have the privilege of working with 40 pediatric telephone nurses who have specialized in this field. Their critiques and feedback are invaluable.

In addition, I work with 30 ED physicians who see the patients our call center refers in, and they have no hesitation in questioning my triage guidelines or judgment if we over refer to them. If their concern makes sense, I make changes in the protocol. I also have over 400 primary care physicians (PCPs) throughout Colorado, half of whom have trained here, that give me feedback if they think we have over referred or under referred one of their patients. For any under referral, we always do a complete review of the complaint, including listening to the phone encounter which is automatically recorded on all calls.

I also receive unexpected communications from nurse managers, medical directors and triage nurses in various call centers throughout the country. I value these questions and critiques. I respond to them directly and make appropriate changes in the protocols when indicated. In summary, I welcome input from anyone who uses my clinical content.

What are some of the health care goals behind your triage protocols?

  • Prevent all under referrals of emergent or urgent conditions (safe care).
  • Minimize over referrals (unnecessary ED and office visits) (cost-effective care and family-focused convenient care).
  • Help triage nurses use the most appropriate protocol through optimal search words and cross-linkages.
  • Provide the caller with targeted, current health care information/education.
  • Educate callers about misconceptions that lead to frequent unnecessary calls (e.g. fever, phobia, green nasal discharge, or productive coughs).
  • Achieve more than 98% triage nurse satisfaction with clinical content.
  • Achieve more than 95% caller satisfaction with service provided.
  • Achieve more than 90% primary care physician concurrence with decision-making.
  • Continuously improve clinical content by incorporating user feedback, reviewer feedback, quality improvement outcomes, research outcomes, and the current medical literature.

How do the philosophies of the three versions differ?

  • All versions use the same criteria for recognizing 911 symptoms or conditions.
  • All versions have similar triage questions and care advice. This helps with consistency of care. Mainly, the dispositions within each set are different.
  • The After-Hours version is for evening, weekend, and holiday coverage by call centers or physicians. Approximately 20% of patients are referred in to the ED or UCC. Whenever it is safe to do so, patients are referred to the physicians’ office on the following day.
  • The Office-Hours version is for triage when the office is open. No one is sent to the ED without the PCP prior approval. Approximately 50% of callers are brought to the office. Anyone who wants to be seen is worked into the office schedule. The remaining callers are provided with specific home care and self-care advice. The software version of office-hours triage is an expanded version of the book the AAP distributes to office pediatricians. This has the advantage of having the parent hear the same advice from the call center and their PCP’s office.
  • The managed care version is for health insurance companies. If a caller needs to be seen and doesn’t need to go to an ED, they are re-directed to call their PCP for further triage. Those who can safely be treated at home are advised similarly to the other versions.

Tell us about HouseCalls Online.

HouseCalls Online are Internet-based self-care guidelines. There is both a pediatric and an adult version. They are available in English and Spanish. Over 20 hospitals currently have them on their website and most report frequent use and a lowered call volume; in essence, they are off-loading some of their low-acuity calls to the web. An exit survey to one website documented 100% of parents thought both the triage and advice they received were understandable and easy to use and 60% said it prevented a call to their doctor’s office. An added benefit is that the content is compatible with Schmitt/Thompson nurse triage guidelines. Some call centers have launched marketing campaigns to redirect unnecessary calls to this resource.

Tell us about the after-hours call center program at The Children’s Hospital (TCH).

It is in Denver, Colorado and was established 1988. It is a statewide system in Colorado and Wyoming.

Will you highlight the stats for the call center?

  • Volume: 10,300 calls per month (2002)
  • Total: 123,000 calls/year (2002)
  • Provided for 477 physicians
    • Private physicians: 337 (324 pediatricians and 13 family physician)
      (includes 98% of metro Denver pediatricians)
    • Kaiser Permanente physicians: 140 (50% pediatricians)
  • Provided by 40 Pediatric RNs (both full-time and part-time)
    • 1 RN can cover 15 pediatricians
    • 1 RN can take 6 calls per hour or 42 calls per shift
  • Disposition of TCH Nurse-Triaged Calls
    • See patient after hours: 20% (admission rate 1:88 calls or 1.1%)
    • See patient within 24 hours: 30% (usually in physician’s office)
    • Telephone advice for home care only: 50%
    • Excludes: advice-only calls 6%
      • Clinical Nurse Manager: Kris Light RN
      • Software Systems Coordinator: Teresa Hegarty RN
      • Medical Director: Barton Schmitt MD

Thank you for taking time to share with our readers.

Thank you

Peter Lyle DeHaan, PhD, is the publisher and editor-in-chief of AnswerStat. He’s a passionate wordsmith whose goal is to change the world one word at a time.  Read more of his articles at

[From the Fall 2003 issue of AnswerStat magazine]

Case Study: University of Texas, M. D. Anderson Cancer Center

By Laura LaLuzerne

The University of Texas M. D. Anderson Cancer Center has provided care for more than 520,000 people with cancer since 1944. The M. D. Anderson Cancer Center has built a worldwide reputation for excellence in cancer patient care, research, education, and prevention.

During 2002, the M. D. Anderson Cancer Center had more than 60,000 patients, including 22,000 new patients. There were 471,728 outpatient treatments, procedures, and visits. In addition, there were 18,781 inpatient admissions. M. D. Anderson has approximately 13,000 employees, including clinical and research faculty.

A Call Center Challenge: M. D. Anderson had three separate call centers to handle the large call volume for its patients and employees. One call center handled institutional calls, another handled patient information calls, and still another handled new patient referral calls. Combined, these three call centers answered approximately 250,000 calls each month.

Managing and staffing multiple call centers was difficult, so M. D. Anderson began to search for a better alternative, one that would allow them to offer more services. According to Mark De Los Santos, Director of the Welcome Center at M. D. Anderson, “M. D. Anderson had a strategic vision where we wanted to take call processing within the institution. We wanted to be able to do what a normal institutional operator does, which is basically route calls, initiate pages, and everything else, but over and above that, we also wanted to be able to offer true answering service capabilities to our physicians.”

M. D. Anderson Welcome Center: After an extensive search, M. D. Anderson was able to merge their three call centers into one Welcome Center, with the implementation of the 1Call Infinity and eCreator systems in December 2002. De Los Santos said M. D. Anderson chose 1Call because it “offers telephony processing, just as any institution would look for, but also offers more. 1Call offers messaging and the ability to create scripting within the system via eCreator, whereby I can control the quality of the call regardless if you are only on the job one week, or 20 years. And based on the people I talked to, 1Call’s customer service was rated as highest.”

M. D. Anderson’s new Welcome Center Attendants are universal operators that can handle any type of call. Using Infinity and eCreator, they’ve watched their average call time drop from one minute per call to 30 seconds per call. The same amount of information is conveyed, but the calls are handled faster.

Additional Services: The Welcome Center Attendants now also act as Customer Service Representatives for the institution. Employees with telephony problems call in to the call center. Their information is entered and is then automatically faxed to the technicians.

The M. D. Anderson call center now handles Help Desk calls for their Human Resources Department. Operators enter what the person is looking for in the employee’s individual account in the Infinity system. They then use scripted questions to drill down using eCreator’s decision tree to find an answer for the caller.

Future Plans for the M. D. Anderson Welcome Center: M. D. Anderson is looking forward to implementing the Infinity Conference Bridge, which will give them the capability to connect up to 30 callers per conference. With researchers located globally, M. D. Anderson often has 15-20 people from around the world on a single conference call. It is estimated that they will be able to handle 98-99% of their conferencing needs internally, saving about $10,000 for the institution each month. Plans also include using the 1Call Infinity and eCreator systems in all of their business centers (clinics), so that their entire facility is on a single platform.

For more information about 1Call products, call 800-356-9148.

[From the Fall 2003 issue of AnswerStat magazine]

Case Study: MASCO Service, From Call Center to Contact Center

By Gary DuPont

MASCO Services Inc. (MSI) has evolved since 1976, when they began providing telecommunications and basic operator services to Boston area hospitals and colleges. The business reached a crossroad in 1991 when the call center had to be relocated to corporate headquarters. The company’s major healthcare customers needed to respond to a changing environment and pressure to become more cost efficient. Those same clients also wanted voice systems services not available with the existing Centrex system. Critical decisions had to be made regarding the selection of new systems to replace major components including the existing Centrex system, a homegrown directory, and radio paging mainframe database.

At that time, MSI was faced with altering the fundamental way of conducting its telecommunications business. The decision was to focus on call center solutions and create an efficient and professional front door to the customers’ organizations.  This was accomplished by shifting from one of the largest shared Centrex systems in the United States to PBX equipment owned by individual institutions. Over the years, MSI has made strategic changes in the “what, who, and how” of service delivery.

With the relocation of the call center to its new facility in January 1993, the three service areas including centralized attendants, paging, and the message center were combined. Integrating the Avaya Definity PBX with a very flexible Local Area Network (LAN) based directory and paging system by Xtend Communications achieved a customer focused, cost efficient solution.

“Our customer service reps (CSRs) are really the front lines of the institutions and clients we serve. In the course of their day, they may be called upon in vital life or death situations to deliver critical service,” said Walter Mont, Contact Center Supervisor. “We recognize how crucial customer service training and product delivery are to performing our function successfully.”

The improved control software in the new call center gave MSI more versatility, better tracking, and general improvement in the paging system due to an equipment upgrade and quicker response time.  Increased standardization with less complexity correlates to improved efficiency and customer satisfaction.

Historically, the MSI call center has been a place where customers’ calls were processed by CSRs using automatic call distribution (ACD) technology. Recently, the MSI call center has evolved into a hub for many different types of interactions using varied technologies, media, and interfaces. These interactions include Computer Telephone Integration (CTI), Web Integration, speech recognition, fax, email, and VoIP (Voice over Internet Protocol).

MSI recently developed a speech recognition application and desktop web based directory and paging for internal use at Beth Israel Deaconess Medical Center and Dana-Faber Cancer Institute. A caller can say the name of the person they are trying to call or page then this technology will route them accordingly. Web-based directory and paging by Xtend Communications provides an efficient tool for accessing extension numbers, text messaging, and on-call information. These technologies off-load routine calls from the operator services staff allowing for additional time with external callers who may require more care.

Today, MSI provides a wide array of contact center solutions to some world-renowned medical and academic facilities in the Boston area such as Beth Israel Deaconess Medical Center, Dana-Farber Cancer Institute, and Emmanuel College. Additionally the contact center supports other medical, commercial, and consumer accounts for dispatch, message taking, and order taking. This paradigm shift to multi-channel integration is essential. Technology is certainly one reason but today MSI’s customers require more efficient and cost effective means of conducting business. Often, self-service is not an option for revenue generating calls.

The contact center plays a vital role in the business and maintaining reliability is paramount. “MSI has partnered with us over the years to keep the shared system intact, while creating more flexible processes,” comments Sandra Denekamp, Manager, Telecommunications at Beth Israel Deaconess Medical Center. “Updated systems now make it possible for us to more accurately measure our expenses and we believe we benefit from a cost, training, and efficiency perspective, by participating in a shared system.”

Because a significant portion of MSI’s business is medical, all of its systems are redundant. The company is constantly fine-tuning its disaster preparedness plans. Next year, MSI will upgrade all of its voice and data systems as well as its networks. As a result, the company will have the capacity to deploy more home-based agents.

Last year, MSI contracted with an independent marketing research firm to measure the service of call center attendants at six specific hospitals on 11 different days, and at six times throughout the day. According to their report, the two top-ranked hospitals, both MSI clients, “stood above all others because of their efficiency in handling calls, and their professionalism. The attendants were friendly and upbeat, helpful and confident. They made one feel as though they care and enjoyed their job.”

Gary DuPont is Director of Telecommunications and Customer Care at MASCO (Medical Academic and Scientific Community Organization, Inc).

[From the Fall 2003 issue of AnswerStat magazine]

A Call to Outsourcing

By Paul Spiegelman

Today’s consumers have higher than ever expectations concerning customer service. They shop for products more judiciously than ever and they turn to the full range of information technologies at their disposal to aid them in their buying decisions. As a result, industries throughout America are being challenged to become more and more sophisticated in their marketing efforts and in building true customer relationship management programs. One of the industries being challenged the most is healthcare.

While America’s medical technology remains the wonder of the world, these are formidable times for those running hospitals, building customer loyalties, and being accountable for each new marketing endeavor or capital expenditure. It is within this environment, and with increasing prevalence that healthcare organizations are recognizing that a well-run call center can capture marketshare, drive revenue, and provide a much-needed compass towards wise utilization of marketing dollars. Grounded in this realization, an increasing number of hospitals are taking a fresh look at the “build versus outsource” crossroads when contemplating how to handle their organization’s call center needs.

Over recent years, outsourcing has become the road more traveled. Little by little, the proven record of accomplishment of the nation’s leading outsourced call centers is stripping away many of the long-standing emotional and organizational barriers that kept the service 100 percent in-house in the 1980s and 1990s. Managers who once felt that their own survival depended upon doing everything internally, or who followed a company philosophy to “build everything internally,” are recognizing the value of outsourcing and are being rewarded many times over for that shift in thinking.

What these managers have discovered is that in many cases outsourcing their call center can provide demonstrative value to their organization in areas such as staffing, service levels, availability, productivity, accountability, and technological capabilities.

Staffing: Outsourced call centers shield an organization from the headaches and hassles that come with staffing – from recruiting to training to managing a call center staff who historically have a propensity to be short-term employees. Outsourcing also provides an organization the flexibility and “bench strength” to adjust their staffing as needs dictate – not having people sitting around when the calls aren’t there or allocating more representatives when there is a spike in calls triggered, for example, by an aggressive advertising campaign or the launch of a new service line.

Service Levels: Because handling phone calls is the only thing outsourced call centers do, such centers have much higher service levels. Calls are answered more quickly, wait times are reduced, multiple languages are often spoken, and in general, a higher degree of customer satisfaction usually results. For a hospital and its medical staff, this can reap both short-term and long-range rewards.

Availability: While it may seem unusual for someone to be seeking a physician referral at 2 a.m. on a Saturday, illness knows no time. Services such as telephone nurse triage need to provide patients and physicians alike with ’round-the-clock peace of mind. It is imperative for a hospital to capture a potential customer at their moment of interest. Outsourced call centers have the capacity to staff 24/7 much more easily than in-house operations.

Productivity: Outsourcing improves a hospital’s productivity by encouraging them to focus on core competencies and critical business issues. Hospitals and doctors are there to provide patient care and clinical expertise, not to answer phones.

Accountability: For years, healthcare marketing and public relations professionals have been challenged to find a credible method for measuring return on their marketing investments. Fortunately, tools are today available that can conclusively tell what’s working and what’s not, what’s generating revenue and what isn’t, and what makes financial sense and what doesn’t. The key to this process is the intelligent use of call centers that are equipped with software packages focused on revenue reconciliation and marketing return on investment. Outsourced call centers are becoming increasingly focused in these areas and are training their call advisors on how to glean the required information from callers and input it into the database. A call center’s ability to provide this data to its hospital client in an understandable and actionable format is something organizations should demand when selecting a call center partner.

Technology: The technological resources available today have added massive new challenges to the complexity of establishing a state of the art call center, and it’s not just the phone. Smart organizations are understanding that the key to customer service means allowing your customers to interact through whichever medium they feel most comfortable, whether that is the phone, the Internet, fax, etc. That means converting a traditional call center into a true customer interaction center where real time chat, prompt email responses, and other forms of two-way communication become the norm. Hospitals can easily waste thousands, if not millions of dollars, buying inappropriate technology or services that quickly become outdated. By avoiding an investment in non-core business functions, capital funds become available for other purposes such as medical technology or physical plant improvements.

Outsourcing is an important, emotional decision for a healthcare company, particularly when it involves something as mission-critical as managing customer relationships through a call center. But recognizing core competencies and acknowledging what is best performed by others is one of the most important tactical decisions any well-run, winning organization can make.

Paul Spiegelman is co-founder and Chief Executive Officer of The Beryl Companies, which, since 1984, has provided a comprehensive range of outsourced call-center solutions to more than 500 healthcare organizations nationwide. Paul can be reached at 817-799-3700 or

[From the Fall 2003 issue of AnswerStat magazine]

Welcome To AnswerStat Magazine!

By Peter Lyle DeHaan, Ph.D.

Let me be the first to welcome you to the premier issue of AnswerStat magazine. AnswerStat is dedicated to providing you, our readers with practical, relevant, and useful information about healthcare and medical related call centers. We are an advertiser-supported publication, which allows us to send this magazine to you, free of charge. Here is some more information:

Who Receives AnswerStat?: AnswerStat is sent free to:

  • Hospital call centers and phone centers
  • Medical answering services
  • Other healthcare related call centers.

What You Do: Readers of AnswerStat are involved in:

  • Switchboard / PBX Console
  • Medical Answering Service
  • Nurse Triage
  • Physician Referral
  • Event Registration
  • Scheduling
  • Data Collection / Verification
  • Insurance
  • Other Medical Related Call Center Functions
  • Consultants

You Can Help: As I mentioned, AnswerStat is an advertiser-supported magazine. This means that advertising revenue pays to have the magazine designed, printed, and mailed to you. You do not need to pay for your subscription. The more advertisers we have, the more useful content we can provide to you. If your call center vendors are not advertising in AnswerStat, please encourage them to do so. We will all benefit as a result.

Free Subscription: Let your colleagues and associates know about AnswerStat. They can sign up for a free subscription. The on-line form is quick and easy to fill out, asking only for information directly related to your subscription. Because your time is valuable, we won’t make you to fill out pages of irrelevant information or ask you to justify why you should receive our magazine. That is just who we are, straightforward and no-nonsense.

Calling all Authors: AnswerStat is looking for articles from our readers, those who work every day in medical related call centers and have real-world experience and knowledge that they are willing to share. Regardless of your level of writing ability or skill, we can work with you to turn your article into a quality piece of which we will all be proud. To get started, download our article guidelines from our website.

Our Website: The AnswerStat website is designed to be a useful resource for you, our readers, whom we serve. Here are some of the resources available:

  • A glossary of call center terms.
  • Area code listings, sorted by area code and by state. We also list codes that are being changed, as well as those that could be changed in the future.
  • An on-line version of our Buyer’s Guide.
  • An article archive, including relevant articles from our sister publication, Connections Magazine.
  • A subscription form. It is free and takes less than a minute to fill out.

About the Publisher: I, have over 20 years of experience in the call center and teleservice industry. Most of that time was spent working in a call center in various technical and management capacities. I also spent three years in the vendor side of the industry in customer support, programming, and documentation. For the last three years, I have been working as a consultant, focusing on the needs of call centers. Two years ago I became a magazine publisher with the purchase of Connections Magazine, which focuses on the needs of outsource call centers. The combined experience of consulting for hospital and medical call centers and publishing a call center magazine has brought me to this point – launching a magazine specifically for medical related call centers.

Contact Us to learn more.

Peter Lyle DeHaan, PhD, is the publisher and editor-in-chief of AnswerStat. He’s a passionate wordsmith whose goal is to change the world one word at a time.

[From the Summer 2003 issue of AnswerStat magazine]