North, Frederick

Telemedicine practitioners are familiar with multiple barriers to delivering care at a distance. Licensing and reimbursement barriers are well known and are being addressed at national and state levels by the American Telemedicine Association. Another telemedicine barrier comes in the form of quality measures for diabetes. Minnesota medical practices are currently being compared on the proportion of their patients with diabetes who have attained goals for blood pressure, low-density lipoprotein cholesterol, and hemoglobin A1C. The quality measure for blood pressure specifically excludes measurements taken by the patient, thus precluding blood pressure telemonitoring as a way to meet the blood pressure goal. To counter this barrier, advocacy in telemedicine is needed so that telemonitoring as a data collection tool is included in quality measures.

Although it has been assumed that telephone triage can directly benefit patients by facilitating early diagnosis and treatment, this potential benefit has not been well documented. Using appendicitis cases ascertained from claims data, we compared telephone triage recommendations with what the callers originally intended to do. Over a two-year period, there were 20,230 calls to a telephone triage centre in the US where insurance information was available. Of these, 12,709 calls (63%) had insurance claims made within seven days of the call. Among these calls, 46 had a diagnosis of appendicitis. In 72% of calls concerning appendicitis, the telephone triage recommendation was for a more rapid evaluation than the caller originally intended ( P < 0.0001). In 91% of the appendicitis cases, triage nurses directed callers to care within 8 h, but without triage advice, only 39% of callers stated they would have sought care within 8 h ( P < 0.0001). Telephone triage significantly reduced the delay in care for appendicitis in comparison with what the caller would have done. This suggests that telephone triage potentially reduces the morbidity associated with appendicitis.

We reviewed surrogate calls (i.e. those made on behalf of the patient) to a national triage call centre to determine whether there were differences between calls made by surrogates and self calls. During a three-year period there were 14,646 calls (14% of the total) made by a surrogate on behalf of the patient. Surrogate calls, as a percentage of total calls, increased with the age of the patient from 12% in the 18–34 year age group to 43% in the 80 and over age group ( P < 0.0001). The symptoms of vomiting or nausea and dizziness or light-headedness were significantly more likely to be reported by surrogate callers than self callers. Surrogates reported a higher original intention of taking patients to the hospital emergency department (ED) compared with self callers across all adult age groups (OR 1.64; 95% CI 1.57 to 1.71). A higher proportion (38%) of surrogate calls ended with the nurse recommending an ED visit compared with only 26% of self calls (OR 1.72; 95% CI 1.66 to 1.79). Calls about men accounted for 54% of surrogate calls but only 26% of self calls (OR 3.3; 95% CI 3.2 to 3.4), suggesting that surrogate calls may be a way of increasing medical access for men.

Introduction: Telemedicine options for symptom assessment include both telephonic means (call centers) and Internet sites. Although symptom assessment call centers have been available for decades, symptom assessment over the Internet is relatively new. It is not well known what types of symptoms Internet users are seeking assessment for and whether extant telephone triage algorithms would be applicable to Internet users. Methods: Symptom assessments on a heavily used Internet site ( MayoClinic.com ) were compared with symptom calls to a U.S. call center (Ask Mayo Clinic). Results: Internet users sought symptom assessments about adult symptoms 13 times more often than children's symptoms. In contrast, over the telephone, adult symptoms were addressed 2.1 times more frequently than children's symptoms. Despite the differences in frequencies of adult and child symptom assessments, users of the Internet and telephone callers asked about specific symptoms with similar relative frequencies. Analysis of 20 adult symptom types shared by the Web and call center revealed that by excluding only 2 assessments (nasal symptoms and leg pain) the remaining 18 showed a significant correlation in counts of use ( r 2 = 0.68, p < 0.001 for linear trend). Conclusions: Internet users have symptoms assessed in similar proportions to callers, with a few exceptions. Compared with callers, Web users are much more likely looking for information about adult symptoms. Callers are proportionally asking more about acute symptoms, whereas Internet users appear more interested in symptom assessment of chronic conditions.

Introduction: The H1N1 (subtype hemagglutinin 1 neuraminidase 1) influenza pandemic of 2009 was associated with a large increase in demand for primary care office visits. However, many patients with H1N1 symptoms or exposure could be assessed and treated with telephone protocols. Methods: Specific H1N1 influenza telephone protocols were developed by Mayo Clinic physicians using Centers for Disease Control recommendations. Using symptom calls to a primary care practice in the United States, we captured nurse telephone triage recommendations, telephone antiviral prescriptions, and what callers would have done without telephone advice. We retrospectively analyzed all symptom calls from July 2009 through January 2010. Results: Call volume was 5,596 calls monthly during the peak influenza months, which was 56% above the monthly average of 3,595 calls for the nonpeak months ( p < 0.001). The calls during October 2009 were 111% over the nonpeak months ( p < 0.001). In October 2009, telephone triage nurses gave 412 prescriptions for antivirals accounting for 5.4% of calls and 39% of all telephonic prescriptions for that month. In the peak H1N1 month of October, there were 1,522 callers who intended to stay home for their care. For the same month, triage nurses suggested 3,250 of the callers stay home. For an October 2009 appointment capacity of 35,126 visit slots, a potential 5% capacity was preserved. Conclusions: A telephone triage solution for the acute demands of influenza H1N1 demonstrated how patients had needs met telephonically while preserving medical access for others.

Adverse events such as deaths following telephone triage calls are rare, suggesting that the process is basically safe. However, if calls tend to concern mostly minor illnesses, then adverse events following calls would be uncommon even if the triage process itself was flawed. We investigated hospitalization rates following triage calls and compared them to hospitalization following two other types of medical access, emergency department (ED) visits and office visits. For the Ask Mayo Clinic telephone triage centre, hospitalization rates for adult calls concerning chest pain and abdominal pain were each 13%. Based on national survey data, hospitalization for adult ED visits concerning the same symptoms were 33% (chest pain) and 19% (abdominal pain). Office visits had hospitalization rates significantly lower than triage calls in all age groups, while ED visits had higher hospitalization rates than triage calls in all age groups. There are both qualitative and quantitative similarities between triage calls and ED visits and, using hospitalization as an indicator, some subgroups of triage calls are nearly as serious as ED visits.