Tag Archives: telephone triage articles

Why Telephone Triage Nurses are a Perfect Complement to Telemedicine


By Charu Raheja, Ph.D.

Telemedicine has been a medical buzzword for several years, and the variety and depth of services provided have grown dramatically during this time. There is little argument that telemedicine is a great way to supplement traditional medical practices.

The advantages are clear: more convenient care for patients, more doctor availability, and less driving time and waiting-room time. But like any other new evolving field, there is still a learning curve and a need for developing a process that makes telemedicine viable, profitable, and doesn’t require doctors to work 24/7 to meet patients’ requests.

One of the biggest hurdles for doctors is that their time with patients is limited. In a traditional office setting, doctors have a nurse start a patient visit before the doctor comes in. Nurses take vitals, talk to patients, and evaluate their needs before a doctor walks in the room. The same type of process needs to be designed for telephone medicine, with the difference being that the nurse will do her job over telemedicine, just like the doctor.

First, some practices have nurses in their office taking patient calls and scheduling visits with a doctor. When managing these calls, the nurse needs to perform two tasks. First, the nurse must evaluate whether or not the patient needs the doctor at all or whether the nurse can help the patient over the phone with home care advice. Second, the nurse must document patient symptom information before making the appointment for the patient to speak with a doctor.

This is where having a good platform to document patient calls and ensure standard protocols comes in. This can ensure patient safety and help make the process efficient. Medical protocols such as Dr. Schmitt and Dr. Thompson’s protocols ensure a standard care every time a nurse takes a call. These protocols are also available electronically, making them easier to use as compared to textbooks. The electronic protocols can also allow the care advice to be documented directly on the patient chart for review by the physician during the telehealth visit.

However, not all doctors offering telehealth services have their own nurses always available to answer patient calls when they first come in. An alternative for these doctors is to hire a telephone nurse triage service. A nurse triage service can serve as an extension of the office by providing patients with a trained nurse to evaluate patient symptoms and determine what actions to take.

What sets a high-quality telephone nurse triage service apart is the ability for the physician to have custom orders and preferences built into the system so that the nurses can act as a true extension of the physician. A high-quality nurse triage nurse service is also able to schedule the patient appointments for those patients who need an appointment.

Providing patients with access to triage nurses can also be helpful for those doctors who don’t have the ability to provide telehealth services 24/7. If given the appropriate instructions, triage nurses are typically able to resolve over 50 percent of the callers’ issues without the need of a doctor.

Figure 1 comes from a survey of over 35,000 patient phone calls. In over 50 percent of the cases, the nurses were able to resolve the caller’s medical symptoms by giving them home care advice. These nurses were also able to determine which callers required a physical visit to an urgent care or an ER (in an event of an emergency, such as symptoms of a potential heart attack).

Telephone nurse triage allows a practice’s telemedicine program to work seamlessly, whether the office is open or closed. Setting up a nurse triage system where nurses use standardized protocols to answer patient questions increases the productivity and profits for your practice.

When your nurses use triage protocols, you can have the confidence that they are asking the right questions and not missing anything. The basic patient information, the protocols used, and the nurse notes can also be used as a quick reference for the physician prior to the telehealth visit similarly to the notes that the doctors receive when their nurses see a patient before them during a physical office visit.


Charu Raheja, Ph.D., is the CEO of TriageLogic a leading provider of quality, affordable triage solutions, including comprehensive after-hours medical call center software, day time triage protocol software, and nurse triage on call. Customers include both institutional and private practices. If your hospital or practice is looking for information on setting up a nurse triage service, contact TriageLogic to get a quote or set up a demo.

Telephone Triage Research: Right Staff, Right Stuff

By Sheila Quiler Wheeler

Broadly speaking, telephone triage is a form of pre-hospital clinical care, albeit by phone. All clinical care implies a standardized approach and system components, similar to any other clinical subspecialty.

Telephone Triage Decision-Making Safety Research

The task of telephone triage involves assessing symptoms of invisible patients with a range of emergent to non-acute symptoms. As telephone triage clinicians we must insure the safe, timely assessment, and disposition of patient symptoms via the phone. Our challenge is to get the patient to the right place, at the right time, for the right reason.

In 2013, I authored a review of literature on telephone triage with a team of experts. We found that patient safety is a persistent topic in telephone triage research. Reviews of past research did not differentiate between clinicians’ and non-clinicians’ respective safety.

For example, four groups of decision makers—both clinician and non-clinician—perform aspects of telephone triage: physicians (clinician), nurses (clinician), emergency medical dispatchers/EMD (non-clinician), and clerical staff (non-clinician). We compared the four groups, reviewing studies between 2002 and 2012, looking for evidence of safety: complete systems and safe dispositions—that is, timely access to appointments.

Safety is likely related to the clinical expertise of the decision maker. While clerical staff and EMDs were not found to be safe, nurses had the highest percentage of safe dispositions, followed by physicians. While telephone triage nurses have minimal systems, traditionally, physicians have little or no training, telephone triage guidelines, or standards; frequently they do not document calls.

When compared to nurses, physicians’ practices appear to not have significantly evolved since the 1950s. Many experts believe that physicians’ practices will not likely change soon. Yet, telephone triage is rapidly growing, requiring expanded patient access and increased formalization. Thus, we believe the best approach is to focus research exclusively on nurse-staffed clinical call centers and to explore ways to improve their systems.

Telephone Triage System Research

In 2016, I conducted an informal online survey of RNs visiting teletriage.com. The survey explored RNs general perceptions of the quality and safety of system components: standards, training, guidelines, and EMR. Respondents to this anonymous survey were encouraged to be candid. Results of the 132 respondents are combined (36 were managers/administrators and 96 were staff nurses).

My purpose was to get a general idea about clinicians’ perceptions of safety and quality of telephone triage system components. Although the survey was informal and small, there were some interesting results, discussed below. Clearly, after fifty years, there is still a need for improved system components and training in telephone triage.

Type of Facility: The largest number of respondents worked in clinics and offices. It was surprising that hospitals were ranked second, followed by clinical call centers. It is unclear where exactly in hospitals telephone triage is taking place.

Populations Served: Most nurses served both pediatric and adult ages. A small number served pediatric populations exclusively.

Standards Usage: Most respondents had standards for telephone triage; the quality is unknown.

Type of Training: Most respondents had some training, with the majority having on-the-job training, and thirty-six having on-site training. Six respondents had no training. Training appears to be variable in content and quality.

Training Quality: Respondents ranked training quality as excellent: 29; above average, 43; average, 44; fair, 7; or poor, 3. Training content is unknown—whether in clinical decision-making or operation of electronic softwarethe first being a clinical skill and the second a technological skill.

Type of Guidelines: Respondents use electronic only, 59; both paper and electronic, 32; paper only, 33; or no guidelines at all, 8. Minimally, every facility should have at least paper guidelines.

Consistent Use of Electronic Guidelines: Respondents used electronic guidelines all the time, 49; most of the time, 36; half the time, 3; or rarely, 3.

Electronic Guideline User Friendliness: Respondents ranked electronic guidelines user friendly all the time, 15; most of the time, 66; half of the time, 7; occasionally, 2; or never, none.

EHR User Friendliness: Respondents found the EHR as user friendly all the time, 13; most of the time, 61; and half the time, 9.

Telephone Triage Outcomes

Given the conditions of uncertainty and urgency in our practice, it is concerning that malpractice cases still often involve the following failures and system error:

  • Use of clinically unqualified staff to assess symptoms
  • Failure to speak directly to the patient
  • Inadequate preliminary assessments
  • Inadequate documentation
  • Inadequate training

The survey summarized above presents rudimentary evidence of existing system failures, which is defined as “Failures of systems, processes, or conditions—intended to prevent errors from occurring—that might lead people to make mistakes.” Identified system errors include “wrong person, wrong task,” “Wrong match of plan to problem,” or “Failure to use any plan” to prevent error (Institute of Medicine). What’s needed is to provide quality guidelines, quality training, or complete system components.

It is reasonable to assume that, at a minimum, safety (good outcomes) begins with using qualified staff that is supported by a complete system: What is a system? A set of detailed methods, procedures, and routines formulated to carry out a specific activity or solve a problem. Donabedian defines quality as structure and process that results in safe, quality outcomes.

Structure: Quality System Components

  • Qualified staff in adequate numbers 
  • Training program
  • Guidelines
  • Standards
  • Documentation

The Nursing Process

  • Assessment
  • Working Diagnosis
  • Plan
  • Evaluation

Outcomes: Safe outcomes are timely, that is, coming early or at the right time.

  • At the right time
  • In the right place
  • For the right reason (See 5-Tier Triage)

Right Staff and Right Stuff

If a malpractice lawsuit occurs due to patient death or harm, telephone triage expert witnesses will request to review the following components of your system:

  • Guidelines
  • Training materials
  • Job qualifications and description
  • Standards (policies and procedures)
  • Call documentation (EMR)

Two initial recommendations based on these research projects are:

  1. Clinicians should manage symptom-based calls: Using non-clinicians to manage symptom-based calls may produce an unintended consequence of error. In the interest of safety, we recommend that nurses or other clinicians take symptom-based calls directly.
  2. Improve current nurse-staffed clinical call centers: While more complete, clinical call centers still need improvement: formal standardized training and improved call center and practice standards. To date, no independent peer-reviewed research has shown electronic decision support software to be reliable or valid. Some researchers have found that nurses are not actually using the electronic guidelines as instructed. The study indicated that, even when using guidelines, nurses still under referred 10 percent of patients.

Since 1984, Sheila Quilter Wheeler, RN, MS has pioneered the field of telephone triage through guideline development, conference development, research, expert witness, and consulting work. Her company, TeleTriage Systems, is located in San Anselmo, CA

Do Mobile Apps Belong in Telephone Triage?

LVM Systems

By Mark Dwyer

Being a “digital immigrant,” whose knowledge and comfort with mobile apps is admittedly deficient, over the past thirty years I have championed the value of a traditional, phone-based nurse triage call center. If I need clinical help (or vendor assistance, for that matter), I still prefer a phone call to interact with a person.

To me, texting, emailing, tweeting, or communicating by any other non-voice-to-voice method, not only can be cold, impersonal, and incomplete, it is often intimidating. Despite claims to the contrary, the developers of many mobile apps have compromised ease-of-use for faster programming and meeting product release deadlines.

That said, I do see a number of scenarios where having access to a mobile app or other software-based solution offers a real benefit to the consumer and a natural tie-in to today’s nurse triage call center. Let’s begin by looking at a few functions commonly used today in telephone triage call centers to which mobile apps are being interfaced.

The Triage Nurse Callback Queue: The follow-up call queue is of weighty value especially when new patients call and all of the call center nurses are busy speaking with other patients. Here, assuming the call is of a non-critical, low-acuity nature, a non-clinical staff member could advise the patient that no nurse is currently available and he or she would gladly add the patient to the nurses’ callback queue once some initial information is gathered.

Web or Mobile App Requests for a Nurse Follow-up Call: For some, enabling the patient to send a summary of their conditions via a smartphone app would be the logical starting place for a phone app interface. Many hospital call centers have begun accepting this kind of communication.

Using the triage nurse callback queue for outbound calls to the patient enables the nurse to review the text sent via the mobile app. Once reviewed, the nurse calls the patient back to engage in a more in-depth conversation regarding the details of the patient’s symptoms.

As always, if the patient is experiencing critical symptoms, they should always be instructed to hang-up and dial 9-1-1 or proceed to the nearest emergency department.

Prioritizing Calls in the Callback Queue by Acuity: The best way to verify that each call added into the nurse callback queue has been assigned an appropriate acuity level would be to have all calls reviewed, assessed and, if needed, adjusted by acuity. To facilitate this, many sites have a charge nurse responsible for managing the queue throughout the day, making sure the highest acuity requests remain listed at the top of the “requests received for nurse call-back” queue.

But this is an article on mobile apps. Isn’t there a way to review and assign an appropriate acuity level with a technological solution instead of needing to manually review each request using a process that requires the addition of more staff?

Natural Language Processing: A more technologically advanced option would be to utilize one of the industry’s natural language processing (NLP) mobile apps. An NLP system can read, at the time of the initial call, the notes captured by the non-clinical, front-end intake person or directly by a call center nurse. The NLP can then interpret the notes into their clinical equivalents, assess the acuity of the call, and send the call to the follow-up queue or make it available to the nurse, in both cases with the appropriate acuity level.

There are systems that can automatically assign an acuity ranking to each call before adding it to the nurse callback queue. If the call is being handled directly by the call center nurse, this same information can be provided directly to the triage call center nurse to help direct her guideline selection. Doing so substantially reduces the time needed to manage the queue. Instead, the charge nurse could be used to provide greater value to patients by handling additional live triage calls.

Again, if needed, these calls could be assigned a higher or lower acuity level by the charge nurse monitoring the queue. When functioning correctly, the auto-feed, queue-sorting algorithm should take into consideration newly added calls every two to three minutes. Generally, callbacks should be made within thirty to forty minutes of receipt of the initial request.

Live Chat Technology: Another option traditional nurse triage call centers are beginning to embrace is utilizing live chat technology to enable the patient to directly interact with a triage nurse within just a couple of minutes of the initial inquiry. Here, via the chat function on most computers and smartphones, the patient can simply enter a brief description of his or her symptoms and send it to the call center. A triage nurse opens the chat, reads the patient’s notes, and then enters an educational or directive note back to the patient again in the chat window.

The nurse’s reply, along with the patient’s initial message, is returned to the patient for further review. If the patient is satisfied with the nurse’s response, he or she simply closes the open chat link. Otherwise, the chat can continue. Once the final message is sent, click to close the chat window. Be sure to follow organizational HIPAA privacy rules.

Using the chat function can be a great productivity benefit because a single nurse can manage multiple chats simultaneously. Just be sure, if chat is implemented in the call center, clearly segment each caller’s or patient’s data from all others to avoid inappropriately sharing personnel health information (PHI) with the wrong individual.

Self-Assessment via Guided Questions: Another mobile app gaining popularity in the telephone triage world is often referred to as a symptom checker. This app provides patients with the ability to self-assess their symptoms using a web or phone-based app. These programs typically begin by providing instructions for using the app and the site’s privacy rules.

When the patient is ready to begin, two diagrams appear, one male and one female, with several body regions defined (such as upper right leg, lower left leg, neck, etc.). The patient can rotate the body to indicate the concern has something to do with an area on the back. Once the body region is identified, the patient clicks on it to display a list of symptoms from which to choose (for example, muscle ache, sunburn, laceration, etc.).

Typically, these programs present a user-friendly interface with self-triage guidelines or some other healthcare information pertaining to the issue the patient is having. If the patient prefers to speak with a nurse, some of the more advanced symptom checker apps will enable the patient to request a follow-up call from a call center nurse.

The patient’s request is added to the nurses’ follow-up call queue. The process continues from there, processing the request much like the steps for chat follow-up interactions, except that the subsequent contacts take the form of phone calls instead of chat texts.

Photo of Wound: This is a surprisingly simple, yet significant feature of many remote apps tied to triage call centers. One of the greatest challenges of performing remote patient triage is the inability to see the patient’s symptoms or problem visually. By adding the ability to share a photo with the call center nurse, the patient can greatly enhance the nurse’s ability to successfully triage the issue.

It is true. A picture is worth a thousand words. These photos are typically shared as jpg files and are stored as part of the patient’s overall triage encounter record.

Video of Patient Behavior: Another visual tool available from some vendors is the ability to send and store a video of the patient’s behavior. Describing lethargic or manic behavior or the uncontrollable crying or hysterics of a toddler is often difficult for a highly stressed parent. Enabling the nurse to watch a brief video of the patient’s current activities can greatly improve the nurses’ ability to correctly assess the patient’s health issues.

Video-Based Doctor Visits: The last application is a rapidly growing phenomenon that spawned an entire new industry to address what many believe to be one of the greatest challenges of Obamacare: providing insurance coverage to twenty million Americans, while struggling with a major shortage of primary care physicians throughout much of the country.

Through governmental action such as the ACA, millions more Americans were provided government subsidized healthcare. Unfortunately, the vast majority of individuals who initially enrolled in the new programs were those of greatest ill health and costliest conditions. These individuals were also largely without a primary care provider. Consequently, the over-crowded, already backed up emergency departments across the country became even more congested with individuals who had nowhere else to go to receive the healthcare they needed to stay alive. Video-based doctor visits provided a partial solution.

The sharpest players in the healthcare triage call center niche will be those who devise a strategy to integrate with these video-based physician practices, performing both pre and post-visit calls and doing follow-up case management calls to these individuals.

The future is here. Either embrace it or miss this current wave—or might it be a tsunami?

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Mark Dwyer is a 30-year veteran of the healthcare call center industry. Mark is in his sixteenth year at LVM Systems where he serves as COO. LVM Systems provides healthcare call center software. For more information or a demonstration of LVM’s call center solutions contact Carol Zeek, regional VP, sales, at 480-633-8200 x279 or Leann Delaney, regional VP, sales at 480-633-8200 x286






10 Critical Steps of Taking a Triage Call


By Marci Lawing, RN BSN

The goal of every triage call is to make a patient feel comfortable and heard, while at the same time collect the critical information from the patient and get them to the appropriate level of care based on their symptoms.

Step 1: Introduce Yourself. Use your first name, title, and the practice or physician you represent. It’s imperative for you to clearly identify yourself and state your credentials as a nurse employee of the practice for which you work. When you introduce yourself, you create a relationship.

Step 2: Collect Demographic Information. Before you are ready to hear your patient’s concerns, you will need to know some of this basic information. Age, gender, and other data will affect your triage protocols, so be sure to collect all the necessary demographic information. This information is needed so it can be put in the appropriate chart and followed up.

Step 3: Gather Medical History. Get a brief medical history so you do not miss any important surgeries, medications, or relevant medical information from the recent months or years. You’ll want to know your patient’s medical history before they detail the current issue.

Step 4: Let the Patient Talk. Now that you’ve armed yourself with all the necessary information you need to proceed, let the patient speak freely about their current concerns. Be an active listener. That means you don’t just listen, but you participate in the conversation by asking any probing questions needed to ascertain a full description of their complaint.

Step 5: Document the Assessment. Once you’ve listened carefully to the patient, document your assessment carefully with the necessary details.

Step 6: Choose the Right Protocol. With the right triage protocol, this step can be fast and efficient. Be sure to document the answer to each question and make any additional notes needed.

Step 7: Get the Patient to the Right Level of Care. Now that you’ve followed the protocols and completed the assessment, you’re ready to recommend the level of care your patient needs. Be sure to speak clearly and at a pace the patient can follow while you detail every step they need to take.

Step 8: Give Relevant Care Advice. Provide solutions based on their symptoms in order to help them find the best path to care.

Step 9: Make Sure Your Patient Knows When to Call Back. Confirm the patient fully understands your triage advice and knows when and who to follow up with.

Step 10: Offer Reassurance. Make sure your patient is able and willing to follow the plan you discussed. It is important, especially with serious symptoms, that the patient follows your triage advice. If told to go to the ER, verify with the patient that they have access to safe transportation. 

You can’t underestimate the power of empathy. Over 80 percent of patients who call in to their physician’s office may not need urgent care, but they all urgently need empathy, someone to listen, and someone to care. That’s the role of the triage nurse. In addition to being a good clinician, a critical thinker, and making sure everyone stays safe, you are also there to provide empathy and care advice to help patients.

These 10 Critical Steps of a Triage Call will help you stay on track and ensure patients get the quality care they deserve.


Marci Lawing, RN BSN, is the clinical nurse manager at TriageLogic LLC. TriageLogic’s online learning center is available free of charge to telephone triage nurses and teams as an educational resource and practical training guide. Along with course videos, coursework includes class notes, related articles, and learning materials. You will receive a TriageLogic Telephone Nurse Triage Certification for each completed course. Managers can also set-up teams and check their individual nurses’ progress in the course.




Selecting a Nurse Triage Consultant

By Gina Tabone, MSN

Healthcare reform has placed pressure on organizations to provide access to clinical care in a manner that improves patient outcomes while appropriately utilizing resources. Nurse triage, a proven mechanism for achieving these goals, can be made even better with the help of a nurse triage consultant.

If you are considering working with a medical call center consultant, your organization is already a step ahead because you recognize the value of industry expertise. As a responsible leader, you will likely select a consultant who can meet your needs, direct your efforts, and ensure success for your call center, organization, and ultimately you. Remember, your reputation is on the line.

Your best interests are served by selecting a consulting group that is established, knowledgeable, and intuitive in respect to remote clinical care. When you’re looking for advice about a specific subject, there is an inherent intelligence that only comes from someone with personal and professional experience in that area. Medical call center expertise is not only a reasonable requirement, but also a vital factor to consider when hiring a consultant to develop a new medical call center or enhance your existing one.

Centralized call centers are rapidly emerging as the backbone of health related systems. Nurse triage offers patients direct access to 24/7 clinical care. The patient populations served by nurse triage programs include primary care, behavioral medicine, diabetics, recently discharged, and chronically ill. The scope of service is vast and so is the network of caregivers.

The call center and services offered, both clinical and non-clinical, do not exist in a vacuum. To be successful there needs to be an endorsement from the C-suite of the medical call center and its value in achieving strategic goals. Executive leadership needs to encourage staff in IT, telephony, nursing, informatics, marketing, and compliance to emphasize that their expertise is essential to the realization and effectiveness of improved access and patient satisfaction.

A medical call center nurse triage consultant provides an objective lens and is able to envision not only what success will look like, but also what needs to be done to attain it. There is no better combination of talents than a consultant who has both medical call center experience and the experience of being a clinician, namely a nurse. Nurses make a commitment to serve the need of the number one benefactor in healthcare: the patient.

Every piece of technology must be selected and implemented with the expectation of a streamlined communication pathway that results in successfully meeting the patient’s needs. Patients primarily prefer contacting providers by phone, texts, or emails. There is also an expectation that whenever illness strikes, a skilled clinician is waiting to help them. That is a reasonable expectation.

Ensuring that patient preferences are understood and provided for is a top priority for healthcare executives. Satisfied patients are often engaged patients, which often lead to improved health outcomes. Improved outcomes result in a better state of health for individuals and the population as a whole. Patients tend to rate their care more favorably and reimbursements are ultimately higher, resulting in the healthcare organization remaining sustainable.

Spending time on-site with a medical call center nurse triage client requires a team effort and ultimately one common goal: optimal patient care. A consultant is provided with a panoramic view of many facets of the operation with a focus on access, clinical care, potential for success and the patient experience. Each health system is distinct, but there is no denying that there are underlying commonalities. Consider these three recommendations when selecting a medical call center consultant:

  1. Only collaborate with subject matter experts who respect that patients come first.
  2. Understand that executive endorsement is imperative for success.
  3. The supreme benchmark that we all must achieve can be found in the answer to a single question: Is what I am doing improving the patient experience?

Gina Tabone MSN is a medical call center nurse triage consultant who teams with various healthcare organizations to develop and optimize medical call center services that exceed patient, provider, and employee expectations. Contact her at gina_tabone@teamhealth.com.







Telehealth Nursing Practice

LVM Systems

By Traci Haynes, MSN, RN, BA, CEN

Health advice has been telephonically dispensed since the advent of the telephone. An often-told story identifies the first telehealth interaction occurring when Alexander Graham Bell placed a call to Mr. Watson, his assistant, requesting Watson to come help him with an injury to his hand.

Today, in our ever-changing healthcare environment coupled with advancing technologies, new methods of interacting with patients and delivering care continue to evolve. Telehealth, in support of the Institute for Healthcare Improvement’s (IHI) triple aim, has demonstrated improved access, quality, and cost-efficiency of healthcare delivery and has resulted in an increased demand for telehealth nursing practice (TNP).

Although TNP had not been recognized as a distinct practice area early on, the breadth and scope has advanced throughout the years. TNP has had a major presence in the United States since the 60s, in Canada since the 70s, and the UK beginning in the 90s.

In the last half of the 70s, health maintenance organizations (HMOs) began using telephone triage and advice services as a gatekeeper, in an effort to control consumer access to care. In the 80s hospital marketing departments used telephone triage as well as physician and service referrals, class registration, and health education and information services to attract and retain their market share. And once again in the early to mid-90s, managed care organizations further expanded telehealth services for demand management, recertification, and referral authorization.

Present day, the ever-increasing incidence of chronic illness and multi-morbidities, as well as the associated rise in healthcare costs, has led to the role of telehealth nurses providing surveillance and monitoring for disease management, care management, case management, care coordination, and clinical prevention programs.

The registered nurse is the appropriate provider of telehealth nursing services as recognized by both the American Nurses Association (ANA) and the American Academy of Ambulatory Care Nursing (AAACN) who also recognize TNP as a nursing subspecialty of ambulatory care nursing. The application of the nursing process when providing patient care has always pointed to professional nursing practice.

Telehealth is used as an umbrella term to describe the wide range of services delivered across distances by all health-related disciplines. The following definitions were approved and adopted by the AAACN’s Telehealth Nursing Practice Special Interest Group (TNP-SIG) in 2003:

  • Telehealth: “The delivery, management, and coordination of health services that integrate electronic information and telecommunications technologies to increase access, improve outcomes, and contain or reduce costs of healthcare” (Greenberg, M., Espensen, M., Becker, C., & Cartwright, J., 2003. Telehealth nursing practice SIG adopts teleterms. AAACN Viewpoint, 25(1), 8-10).
  • Telehealth Nursing: “The delivery, management, and coordination of care and services provided via telecommunications technology within the domain of nursing” (Greenberg, Espensen, Becker, & Cartwright). Telehealth nursing encompasses all types of nursing care and services using one or more types of telecommunications technologies: telephone, fax, electronic mail, internet, video monitoring, and interactive video.
  • Telephone Nursing: “All care and services within the scope of nursing practice that are delivered over the telephone” (Greenberg, Espensen, Becker, & Cartwright).
  • Telephone Triage: “An interactive process between nurse and client that occurs over the telephone and involves identifying the nature and urgency of client healthcare needs and determining the appropriate disposition” (Greenberg, Espensen, Becker, & Cartwright).

State boards of nursing define the scope of nursing practice for each state. Each nurse must be knowledgeable of their state’s Nurse Practice Act and the rules and regulations involving their practice within their state of residence.

In 1999, the National Council of State Boards of Nursing (NCSBN) proposed the Nurse Licensure Compact (NLC), allowing “mutual recognition” of a nursing license between member states. Enacted into law by each participating state, member states allow a nurse that resides in and possesses a current nursing license in a state that is a member of the NLC to practice in any of the other member states without obtaining additional licensure in that state. An excellent video provided by the NCSBN can be found on their website and is titled “The Nurse Licensure Compact Explained.” Currently, twenty-five states are involved in the NLC.

Telephone Nursing Practice certification was offered by the National Certification Corporation (NCC) from 2001 to 2007. In all, over 1,200 nurses were nationally certified. Nurses who are currently certified through NCC can maintain their certification by meeting NCC’s recertification requirements.

In 2007 AAACN adopted the position that TNP has been and continues to be an integral element of ambulatory nursing. In their role as an industry leader, AAACN continues their support of TNP. Today the Ambulatory Certification Review Course and the Ambulatory Care certification exam include a telehealth component.

AAACN further supports TNP with its own telehealth track at their annual conference, as well as providing many resources for TNP including:

  • Scope and Standards of Practice for Professional Telehealth Nursing (American Academy of Ambulatory Care Nursing (AAACN), 2011. Scope and standards of practice for professional telehealth nursing (5th). Pitman, NJ: Author.)
  • Telehealth Nursing Practice Essentials Textbook
  • Endorsement of “The Art and Science of Telephone Triage: How to Practice Nursing Over the Phone,” written by Carol Rutenberg, RN-B, C-TNP, MNSc and M. Elizabeth Greenberg, RN-BC, C-TNP, PhD.

Competencies for TNP as defined by AAACN in 2004 identify the behaviors and outcomes specific to providing efficient, effective, evidence-based care. These include:

  • Professional Knowledge: managing clinical calls using the nursing process and demonstrating critical thinking skills in assessing the needs of the caller.
  • Interpersonal Skills: establishing a trusting relation in order to elicit accurate information and using effective interpersonal communication skills to engage in a therapeutic interaction.
  • Technical Skills: adapting to equipment efficiently in order to perform the TNP role and using decision support tools (such as, guidelines, protocols, algorithms, and care pathways) to address caller needs to identify actual and potential health risks.
  • Documentation of Telehealth Encounters: accurately recording the interaction reflecting the actual or potential health needs, which become part of the EHR.
  • Personal and Professional Development: responsibility for attaining and maintaining the knowledge and skills necessary to function in the TNP role (AAACN, 2011).
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TNP improves access to healthcare for our patient populations. It increases the quality of healthcare outcomes through patient-centered, collaborative care, and decreases the cost of care by meeting the needs of patients with timely and appropriate resources.

Traci Haynes, MSN, RN, BA, CEN, is the director, clinical services at LVM Systems, Inc.





Make Your Office Available for Patients 24/7


Help doctors reduce costs, retain patients, and take fewer after hours calls on their own

By Charu G. Raheja, PhD and Ravi K Raheja, MD

In the new world where patients are requesting on-demand access to doctors and healthcare providers, how can offices or hospitals remain competitive and provide access to healthcare 24/7? The past two years have seen a proliferation of telemedicine, including on-demand physicians that evaluate and prescribe over the phone. Various market research companies predict a growth rate between 15 and 25 percent a year, and according to research analysts and companies, such as Zion Research, the United States’ telemedicine market is expected to reach approximately $35 billion by 2020.

The results are not surprising. Limited access to physicians and caregivers has been a common complaint among consumers. Year after year, emergency departments continue to see patients that should have been handled by family doctors or other outpatient clinics. Some of these patients are now opting to speak to a telemedicine doctor – even if that doctor is not their established doctor – in the hopes of avoiding an unnecessary ER visit.

From the point of view of the patient, both going to the ER and speaking to a telemedicine doctor are reasonable when no other options are available. Imagine, for example, a mother with a newborn that has a low-grade fever or a sixty-five year-old man who is coughing up blood. How do they decide if the symptoms require an emergency visit or if it’s okay to wait until the next business day for the doctor’s office to open? The solution for physicians is twofold: implement technology to ease the patient’s access to offices and make sure the patient has access to a healthcare partner at all times.

The goal of technology is to allow patients to text and communicate with the office using a smartphone app instead of having to leave a message with a front desk and waiting for a callback. Being able to text simple issues such as appointment requests or medication questions gives patients the freedom to go about their day and conveniently keep a lookout for the office’s response. For the office staff this also gives the added advantage of being able to prioritize their responses to the patients. Texting back also guarantees contact with the patient, which saves the staff from wasting time with missed phone calls. Call centers can help doctors by offering them such apps and solutions to improve the patient experience.

As for having a healthcare partner available, a nurse triage line is a great solution for offices where doctors don’t want to take the responsibility of handling all the calls on nights and weekends. Triage nurses are able to handle over 80 percent of the calls without the need to contact a doctor. Having nurses available gives patients the comfort of knowing they have an option through their provider when a health symptom surfaces. For a patient, an emergency is anytime he or she doesn’t feel well. Having a trained nurse who works directly with their doctor’s office can provide them with needed reassurance, prevent further complications, save them from an unnecessary ER visit, and ensure continuity of care.


Charu G. Raheja, PhD is the chair and CEO of the TriageLogic Group. Ravi K. Raheja, MD is the COO and Medical Director of the TriageLogic Group. Founded in 2005, TriageLogic is a URAC accredited, physician-lead provider of high quality telehealth services, nurse triage, triage education, and software for telephone medicine. Their comprehensive triage solution includes integrated mobile access and two-way video capability. For more information visit www.triagelogic.com and www.continuwell.com.

Patient Symptoms and Outcomes


Nurse triage is a perfect bridge to provide 24/7 access for patients to ask questions without adding a significant burden for the doctors.

By Charu G. Raheja, PhD

Often times, as adults, we think we are better than children in determining if our symptoms are serious enough to require further care. As a result, many of us deny very serious symptoms. We think the severe headache is just a migraine. Or that the chest pain is not caused by a heart attack – that only happens to other people. However, we tend to be more cautious when it comes to our children. We often ask for advice when our children have a cut, suffer a fever, or are crying inconsolably.

The truth is that it is more difficult to be objective about our own symptoms than the symptoms of our loved ones. We don’t always want to interrupt our day to find out we have a minor problem, but we do tend to worry when it comes to family members, especially our children. As nurse manager Marci Lawing observed, “Adults will try everything without any assistance and usually only call their doctor or nurse triage line as a last resort. Parents, on the other hand, tend to be a lot more proactive about calling right away if their children experience unusual symptoms.”

We studied treatment advice data from our nurse triage call center for the months of April, May, and June 2016 and compared the triage advice given to adult callers and the advice given to patients ages one and under. In those three months, nurses triaged close to 42,000 callers. About 9,200 were adult callers, and 9,400 were babies under the age of one. Surprisingly, adults had a significantly higher rate of ER referral and a much lower incidence of home care advice.

Compared to the entire population, here is what we discovered about patients 18 years and above:

  • Less than one-fourth of adults are given home care, in comparison to about one-half for the overall population.
  • Adults have a high ER referral rate: one in every three adults is sent to the ER, compared to one in six for the overall population.
  • In both the adult and child groups, about one in three needed to follow up with a doctor’s office within twenty-four to forty-eight hours.
  • We also observed that by following the protocols, nurses most often sent adults to the ER for pain symptoms, particularly chest, abdominal, and back pain.
  • Breathing difficulty and post operation complications were also one of the top five reasons why adult patients were sent to the ER.

Next, we compared the disposition of adult callers to that of babies ages one and under. We initially predicted that babies would have the highest incident of ER or urgent care dispositions, with newborn having the highest rate of ER referral. Because of the different nature of care advice for newborns, we separate newborns between up to sixteen weeks and babies between seventeen weeks and one year.

The results of this comparison are surprising. Contrary to what we predicted, we found babies are sent to the ER at a much lower rate than adults. The results are:

  • More than half of the babies were given home care advice. This is more than double the percentage of adults given home care advice.
  • Babies have a relatively low ER referral rate: only one in nine babies are sent to the ER.
  • Newborns have a higher incidence of being sent to the ER than babies, but this rate is still much less than adults. Roughly two in every eleven babies are sent to the ER, compared to almost one in three adults.
  • Finally, as one would expect, the reasons babies are sent to the ER are very different from adults. The top five protocols used by nurses when they determined the baby needed to go to the ER or urgent care were cough, vomiting (with or without diarrhea), wheezing (non-asthma), and head injury.

This surprising result on the higher proportion of adult callers being told to go to the ER also brings into question whether the age of the caller makes a difference in ER referral rates. Are older adults more likely to be told to go to the ER than younger adults? I divide the adult data in three groups: eighteen to forty year old, forty-one to sixty-five, and over sixty-five years of age. Again, the results are surprising. Most people would expect that the older adults to be the most likely to be sent to the ER. The oldest adult groups were in fact the least likely to be told to go to the ER at only 29 percent.

The data in this article aligns with the general observation that adults tend to wait until they are decidedly sick before calling for professional medical advice. Parents, on the other hand, seem to be much more proactive about calling as soon as unusual symptoms surface, allowing nurses to give home care advice or send babies to the doctor before the symptom becomes a serious condition. Of course, it is possible that the adult population is overall more sick than the baby population since the data does not allow us to measure the overall health of the caller prior to the symptom that led them to call the nurse.

This study also presents the top five protocols used on each group when the nurse determined an ER visit was needed. While not everyone calling with the above symptoms needs to go to the ER, patients need to be told by their primary care providers that these top five symptoms could be the sign of a serious illness and they might need to contact a medical professional for assessment. Nurse triage is a perfect bridge to provide 24/7 access for patients to ask questions without adding a significant burden for the doctors. In addition, patients tend to be more comfortable calling a nurse because nurses are trained to provide comfort and evaluate if a symptom even requires a doctor visit. Doctors, on the other hand, tend to be seen as someone to contact only when you are truly sick, discouraging patients from calling.

If medical facilities implement proper education in the office and access to high quality nurse triage or another form of telemedicine, patients are able to access a trained medical professional and be directed to the appropriate level of care, providing reassurance or preventing morbidity and mortality. In addition, providing a telehealth advice line when the office is closed allows patients to stay with their providers and receive continuity of care.


Charu G. Raheja, PhD is the chair and CEO of the TriageLogic Group, founded in 2005. TriageLogic is a URAC accredited, physician-lead provider of high quality telehealth services, nurse triage, triage education, and software for telephone medicine. Their comprehensive triage solution includes integrated mobile access and two-way video capability. For more information visit www.triagelogic.com.

Health Navigator Adds Spanish and German

Healthcare is confusing enough for consumers, but language barriers increase the complexity. That’s why Health Navigator expanded the language capabilities of its diagnostic platform to include Spanish and German translations to increase access to telehealth solutions for providers and patients. This makes it easier for non-English speaking patients to utilize e-health tools and applications, ensuring greater accuracy when they use virtual care.

According to David Thompson, MD, founder and CEO of Health Navigator, the expanded language capabilities demonstrate the agility, flexibility, and accessibility of the Health Navigator platform. Providing a multilingual platform also broadens Health Navigator’s ability to work with international clients and deliver the same product capabilities regardless of language.

“We are making it easier for healthcare providers to engage and facilitate communication with patients along the healthcare continuum,” said Dr. Thompson. Additionally updates are in progress to add simplified Chinese and French language capabilities to the Health Navigator platform. The new language translations are available immediately to Health Navigator clients and are easily accessible through the application programming interface. There is no additional charge for secondary language functionality for Health Navigator clients.

[Posted by Peter Lyle DeHaan, PhD for AnswerStat magazine, a medical healthcare publication from Peter DeHaan Publishing Inc.]

Emerging Health Coaching Programs Address Multi-Morbidities

LVM Systems

By Mark S. Dwyer and Heather Jacobs

According to the US Centers for Disease Control and Prevention, chronic disease contributes to more than 75 percent of our national health expenditures. Persons with chronic health conditions account for 84 percent of all healthcare spending in the United States and are the most expensive users of healthcare services (Anderson, 2010). Furthermore, according to the Agency for Healthcare Research and Quality persons with multiple chronic conditions cost up to seven times as much as those with only one chronic condition (AHRQ, 2006).

Historically, care plans were designed to independently manage single chronic conditions such as heart failure, COPD, diabetes, adult asthma, pneumonia, and others. These early care plans effectively helped care coordinators assist patients in managing one chronic condition at a time.

But what about patients with multi-morbidities?

A better way was needed to address patients who suffered from two, three, or more chronic conditions. Until now, addressing a patient’s multiple needs meant managing the patient in multiple care plans. Doing so resulted in duplicate calls, redundant questions, and repetitious sharing of health data.

The 2013 AMA recognition of obesity as a chronic disease has further extended the need for integrated care management. Obesity is at epidemic levels throughout the United States. (See part two of Traci Haynes’ article on obesity). Often this directly relates to other chronic conditions such as diabetes, making it no longer realistic to manage these conditions independent of each other.

To address this, comprehensive health coaching programs enable RN care coordinators to manage the health of multi-morbidity patients. These plans help identify the appropriate surveys to complete with the patient, the information to send, the health statistics to gather, and the goals to set, all within a single call. This allows care coordinators to use their critical-thinking skills to identify the appropriate information to share during any call.

How it Works: Patients are enrolled into a single, dynamic care plan that can be customized to meet each patient’s unique needs and multi-morbidities. Once enrolled, contacts between the patient and care coordinator are scheduled as needed as opposed to following a rigid fixed frequency.

As part of the initial and annual follow-up calls, the care coordinator can gather baseline data, medication adherence, and other health information that does not change often. The baseline data allows the care coordinator to assess the patient’s needs regarding multi-morbidities, service needs, adherence to basic self-management, and desire to change behaviors.

There are two primary plan frequencies to consider: comprehensive and high frequency. The comprehensive plan is designed to follow-up with the patient on a less frequent basis (such as, quarterly) while the high frequency plan involves contacting the patient on a more frequent basis (perhaps weekly or monthly). Both plan frequencies address medication adherence, standards of care, and optional goals.

Based on updated standards of care, the care coordinator uses surveys to gather data on the HEDIS and disease-specific medical care standards, as recommended by the corresponding accrediting organizations and authorities. In addition to surveys defined for each disease state, the system also includes the Zung Depression survey and Diabetes Distress Screening (DDS17).

Once the appropriate data is gathered, the care coordinator can access appropriate resources as needed. This information is shared with the patient using email, text, or paper format. Many of these health information topics are authored by the AAFP (American Academy of Family Physicians) or MedlinePlus.

Two other key surveys involve goals and medications. The goals survey is optional on any encounter or may be used as a standalone contact to work with the patient in setting goals and evaluating progress. Although the medications survey is also an option as a stand-alone contact – to work with patients on medication adherence, education, and needed resources – it is recommended to update it with each encounter.

Key reporting tools are available to assist with patient assessment and streamlined call processing. Reports can give care coordinators a quick way to view the patient’s health history, lab values, appointments, and goals. In support of this, an adherence scorecard report alerts care coordinators to any behaviors that need to be addressed during the contact. If desired, the patient’s physician can be notified if the patient opted in or out of the program, any goals identified, DDS17 results, depression screenings, and the patient’s adherence to the standards of care.

Key Components: A comprehensive health coaching program should include the following components:

  • Patient Engagement: A centralized tool to turn referrals into interactions and facilitate the connection and coordination of care across the patient care continuum.
  • Self-Management: Built-in tools to teach patients self-management behaviors, including medication adherence, and self-monitoring (peak flows, blood glucose, weight, and so forth). Medication errors can be avoided with the program’s reconciliation and adherence tools.
  • Patient Goals: Identify care gaps using health risk assessments and surveys to set relevant goals with the patient. Track progress and refer to network providers or community services based on the patient’s benefits.
  • Behavior Change: Drive change with health coaching tools aimed at both the patient and family members. Ongoing contact and consistent messaging managed by the outreach scheduling tool are critical to permanent behavior change.
  • Improved Outcomes: With timely intervention, paired with healthy patient and family engagement, patients are readmitted less often and are more satisfied with their care.
  • Measure Results: Trend readmission rates provide clinical outcome reports to track enrollment and demonstrate success.

In light of the country’s aging population and overall poor diet, the likelihood of individuals needing multi-morbidity care management services in the future is likely to grow. Fortunately, emerging health coaching programs provide the infrastructure upon which to effectively improve care, education, and behavior modification. The result can provide healthier outcomes for patients, increase customer loyalty, and positively affect an organization’s bottom line.

LVM Systems logo

Mark S. Dwyer, COO, and Heather Jacobs, manager of client services, both at LVM Systems, providers of Poly Plan, a health coaching program that provides the infrastructure to effectively improve care, provide education, and encourage behavior modification. For more information, contact Heather at heather@lvmsystems.com or 480-633-8200 x333.