Design and Implementation of a System for Computer-Assisted ...

Design and Implementation of a System for Computer-Assisted Telephone Triage in Pediatrics Richard N. Shiffman, M.D. Private practice pediatrician, Arvada, Colorado Present address: Decision Systems Group, Brigham and Women's Hospital, Boston, MA 02115

ABSTRACT Pediatricians spend a considerable amount of time handling medical problems by telephone. A program was developed to provide decision support, standardization of practice and documentation for pediatric telephone triagers. Written in HyperCard' the program allows rapid access to protocols and a simplified mechanism for documentation of findings. Obstacles to implementation are reviewed.

assessed telephone histories taken by 40 practicing pediatricians for four common complaints and found them sorely lacking [8]. Crucial questions such as difficulty breathing with a complaint of cough, the state of hydration with a complaint of diarrhea and the presence of abdominal pain in patients with vomiting were asked less than 50% of the time. Emergency departments experience a demand for telephone advice 24 hours per day. Verdile et. al. presented a scenario that could reasonably have been interpreted as a patient experiencing myocardial ischemia to 46 emergency departments [9]. They concluded that telephone advice by many emergency departments is nonstandardized and may be inadequate to the point of jeopardizing the welfare of the caller. The intrusive quality of a large volume of telephone calls has proved to be a source of annoyance for many pediatricians. Fifty percent of pediatricians surveyed experienced the telephone as the most frustrating part of their practices [10]. In a study by Caplan, pediatricians found 23% of evening calls and 54% of after midnight calls to be inappropriate and annoying [ 11]. In response to this dissatisfaction a number of hospitals and private groups have begun to provide after hours telephone support services for practicing pediatricians. This paper will examine the analysis and design considerations in developing a a microcomputer based decision support system for telephone triage which might be implemented in pediatric offices, emergency rooms or after-hours call support programs. Potential problems encountered during implementation will be discussed.

TELEPHONE USE BY MEDICAL PROFESSIONALS The telephone has become an integral part of primary care practice. For pediatricians, between 12.5% and 27% of their time is spent on the telephone completing an average of 41.5 calls per week [1,2,3]. In busy offices triage responsibility is often delegated to nurses, paraprofessionals and receptionists. Varying levels of experience and expertise contribute to varying quality of triage and advice. Frequently, no written record is made of telephone encounters. Of the daytime medical calls handled by a pediatric office, approximately 3% represent emergencies, 47% concern sick children who need to be seen by appointment and 50% can be dealt with by providing home treatment advice.[4] The ideal outcome of the triage process would be for all children requiring immediate treatment to be seen immediately and for those children with minor or self-limited illnesses to be appointed at a future time or managed entirely at home. Screening thresholds that are set too low will overwhelm the physician with nonessential work and result in unnecessary economic burdens for the patient. On the other hand, too high a threshold can result in serious illness remaining undetected and untreated [5]. The absence of a capability for direct observation contributes to the potential inaccuracy of telephone assessments. In pediatrics, the complaints are usually interpreted and relayed via a third person who may or may not be known to the triager. Time limitations and such modifying circumstances as time of the call, distance of the patient from the office or the hospital and the degree of anxiety being expressed all have a bearing on the triage process [6]. Several studies have documented relatively poor quality of care provided by practicing pediatricians, house officers and nurse practitioners. Ott et. al. found that pediatric house staff performed marginally in simulated telephone vignettes [7]. Greitzer et.al.

0195-4210/90/0000/0826$01.00 © 1990 SCAMC, Inc.

REQUIREMENTS DEFINITION The target user of the proposed software was defined to be nurses and paraprofessionals working under the supervision of a physician experienced in telephone triage. While physicians themselves might make use a triage program, adherence to a rigid protocol structure was not expected to find favor among experienced physicians. At the same time it was recognized that such a program might prove useful for teaching primary care residents. Protocols would utilize medical nomenclature because of its brevity and specificity, and would thus be inappropriate for use by the lay public. It was intended that a large majority of calls could be handled without need for physician intervention.

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Macartney has observed that next to accuracy, parsimony (using a minimum of data and resources) is the most important criterion by which a diagnostic process should be judged [15]. For health care professionals handling large volumes of telephone calls, getting to the crux of the caller's problem is essential. Since triage -- not diagnosis - is the goal, algorithms were designed to reach one of two general conclusions: 1) See this patient immediately 2) See this patient on an appointment basis or manage the problem at home. In-depth exploration of all possible details of a complaint is unnecessary and inefficient. Data items sufficient to probe a complaint and leading to one of the above conclusions were selected for each of 101 common complaints. The protocol topics were selected by the author to cover a large proportion of call subjects. Each protocol was adapted for use from those published in Pediatric Telephone Advice [4] by Barton Schmitt. Prior to inclusion in this software, each algorithm was carefully reviewed and brought up to date with Dr. Schmitt's assistance. This combined the expertise of a university professor with interest and skills in ambulatory pediatrics with those of the author who is a practicing pediatrician in a suburban practice. Any controversies were resolved by obtaining consultation from subspecialists on the University of Colorado faculty.

Three goals were specified: 1. Symptoms described by telephone should be evaluated in a competent manner. This quality assurance function was central to the entire development effort. If assessments are inaccurate, the software would be valueless. Checklists would be constructed to remind triagers of appropriate questions to discuss. Levy et. al. demonstated that use of written protocols resulted in correct identification of children needing to be seen, needing physician consultation and cases in which children might be safely treated at home [12]. 2. Any advice provided should be consistent over time and from triager to triager. By limiting advice to that provided by protocol, standards of care could be upheld. 3. Documentation of telephone calls should be easy and thorough. In private practice, a significant number of physicians do not retain written documentation of telephone interactions. In a 1985 survey, a majority of pediatric training programs did not encourage telephone record keeping in their clinics and emergency rooms because of lack of personnel, lack of time and lack of conviction that such documentation is medically or legally necessary [13]. However, malpractice suits have been brought because of advice given or not given by phone [14]. Rapid response time to user input, program size allowing usage on a computer with one megabyte of RAM, short training time and robustness were properties considered essential for the final software. As the design process evolved, a number of supplementary capabilities were added including customizeability, onscreen help, summary screens, archiving capabilities and initialization routines. Additionally a tutorial was prepared to assist in the training of new users.

IMPLEMENTATION HyperCard was chosen as the development system for this software, hereafter referred to as Pediatric Telephone Protocols (PTP). The program was coded primarily in HyperTalk with several key routines coded as Pascal XCMD's (external commands). HyperCard was seen as an appropriate medium for a number of reasons. The information to be processed logically divides into screen-sized "cards" which are the elementary HyperCard visual units. A hypertext expansion function is available with little effort. Searches using the Find command are quite fast. Additionally, the ability of the user to customize the knowledge base was considered beneficial. No complicated reports or complex searching patterns are necessary. Finally, the Macintosh® WIMP interface (Windows, Icons, Menus, Pointing) makes its use enjoyable to non-computer literate users and facilitates

SOFTWARE DESIGN Telephone triage data logically segregate into 1) information concerning a specific telephone encounter (e.g. caller identification and complaint) and 2) reference information contained in the protocols to be followed for each call. In order to provide thorough documentation, the findings and management recommendations from the protocols relevant to a specific call ultimately should be recorded together with the call identifying data. Functionally, the user interface needs to be responsive and relatively unobtrusive. The triager is engaged in data collection while speaking with the caller. Excessive typing which would interfere with conversational flow must be avoided. It was decided to create a set of protocol forms listing pertinent questions accompanied by check boxes. Responses recorded by clicking checkboxes with the mouse on a PROTOCOL form would cause a textual summary of findings to appear on the ENCOUNTER forn.

learning [16].

The PHONE ENCOUNTER stack was designed to store information about telephone calls. The assessment/management protocols reside in the COMPLAINTS stack. Caller responses to protocol questions are recorded by mouseclicks on checkboxes in the COMPLAINTS stack and are transferred automatically as text listings to the PHONE ENCOUNTER form. The triager needs only type a limited amount of identifying information at the top of a PHONE ENCOUNTER form after which all

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in the PHONE ENCOUNTER stack the phone interaction regarding a single complaint for a single caller (Fig. 1). The triager logs the following information for each call: Encounter number Age Date/Time Telephone number Physician Complaint Patient Name Call handler The remainder of the card contains fields which are filled automatically by the program with responses recorded on COMPLAINT cards. The fields document positive and negative responses, pertinent past medical history, recommended management and specific followup information. Along the right margin of the PHONE ENCOUNTER form is a series of buttons which facilitates use of the program (documenting date and time of the call, dialing the telephone number, finding the correct card in the COMPLAINTS stack, opening a continuation form for additional complaints, printing a copy of an ENCOUNTER form, flagging a form for later call-back and generating a new form for the next phone encounter). screen

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The COMPLAINT stack is composed primarily of COMPLAINT and RX cards. In addition to their information content, the structure of the COMPLAINT cards (Fig. 2) is a critical component of the knowledge base. Each COMPLAINT card lists from 1 to 15 parameters aimed at reaching a triage decision. As the triager reviews these topics with a caller, the triager clicks on a checkbox preceding each parameter to indicate positive or negative findings. A horizontal triage line separates those issues for which a positive response dictates a need to see the child immediately from those responses for which the child might be evaluated by appointment or managed at home without being seen. The card also allows free-text recording of significant past medical history in a field at the bottom of the card. The identity of the caller is displayed in a patient identification window at the top of the card. "See Also Buttons" and navigation buttons allow rapid movement to other pertinent areas of the COMPLAINT stack. By positioning the cursor over any topic on the COMPLAINT card and clicking the mouse button, the triager can open a "hypertext window" containing a variety of information such as phrasing of a question to elicit the desired facts, exceptions to positive and negative responses, differential diagnostic considerations and reminder notes (Fig. 3). The differential diagnosis listed is not intended to be exhaustive, but rather highlights some important considerations.

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problem can probably be dealt with on an appointment basis or managed at home. The horizontal line is intended as a guide. Parents and on-site observers often have a sixth sense about the severity of an injury or illness that cannot be ignored by the triager using only a single sense to assess a situation. The triager should be instructed to err on the side of seeing patients when concern persists on the part of the caller or the tiager regarding the severity of a problem [17]. After deciding which triage response is supported by the response pattern, the PTP-user clicks either the STAT CARE or the HOME CARE button. Clicking either button records the caller's positive and negative responses on the PHONE ENCOUNTER form. The STAT button also records the statement "SEE CHILD IMMEDIATELY!" in the Recommended Management field and moves to a card on which instructions are recorded for directing the patient to an appropriate facility for immediate evaluation. Such considerations as availability of lab or X-ray facilities and insurance participation may result in alternative suggestions. The instructions on this STAT card may be personalized by the user. Access to an EMERGENCY TELEPHONE NUMBER card (on which may be recorded the phone numbers of ambulance agencies, pharmacies, Poison Center, child abuse and suicide hotlines, etc.) is quickly available from the STAT card.

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After completing the protocol (either the STAT card or the RX card) clicking the return button brings the

PHONE ENCOUNTER form back into view with positive and negative responses, pertinent additional historical data, recommended management and indications for call back clearly logged (Fig. 6). This form may then be printed out or flagged for further attention of the triager. Oat 4/6189

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Fig.4. RX Card for Vomiting protocol. Clicking the HOME CARE button takes the user to the appropriate RX CARD for the current complaint (Fig. 4). The RX CARD contains recommendations for home management of the complaint and indications for the caller to get back in touch with the health care provider. Hypertext windows with additional information regarding a recommendation are available for asterisked recommendations. The triager may also access MEDICATION cards (Fig. 5) for a number of commonly used medications (including acetaminophen and antihistamines) by clicking on asterisked medication names. On these cards, the appropriate dose of medication can be determined by entering the child's weight in pounds and clicking on the dosage form which the caller has available.

Pediatric Telephone Protocols allows the user to personalize the protocols in the COMPLAINTS stack to reflect his/her individual practice. The menubar offers a "Customize" option which allows adding, deleting or modifying parameters, changing the relative positions of parameters in the listing, changing the content of hypertext windows and adding entirely new protocols. TESTING Initially, the author used the program when responding to night calls in his practice for several weeks observing differences between his standard practice and computer-assisted triage. A number of minor changes to the protocols enhanced their utility. As program errors were noted they were corrected.

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limited. In a computerized facility, the computer used by the receptionist for accounting and word-processing functions is often the ideal location but this computer must have a multitasking capability to allow triage and office management functions to coexist. Office noise and privacy considerations may dictate alternative locations. Allocation of financial resources for an unproven technology creates additional problems. PTP requires a Macintosh computer for its operation yet many physician installations do not currently use this hardware. Medicolegally, the use of computer software for decision support of telephone triage is not currently accepted as standard of care. Codifying triage with written protocols may be expected to improve care. However, any deficiencies, either in the system itself or in its use, could put both the supervising physician and the software developer at risk in the event of unfortunate

Next, an experienced triage nurse from the Children's Hospital (Denver) came to the author's office exercising the program using data similar to that which the program was designed to execute. Eventually, the program was tested in the Emergency Room at the Children's Hospital where several nurses gained familiarity with its use and provided critiques. IMPEDIMENTS TO IMPLEMENTATION A number of obstacles may impede the introduction of a computerized decision support system for telephone triage. Initial resistance to new technology is well documented for both nurses and physicians [18]. "Turf battles" between departments interested in implementing a protocol system and those more disinclined to do so may be expected. In an office setting, finding a suitable physical location for the computer may create difficulties. The triage computer must reside in close proximity to the telephone used for appointment-making but this is the part of the office where desktop area is often most

consequences.

14George,

J.E., Telephone triage. In George, J.E. ed. Law and Emergency Care. St. Louis, C.V. Mosby, 1980. 15MacArtney, F.J., Diagnostic logic, Brit Med J,

et.al., Time motion study of practicing lBergman, A.,Ped, 38:254-63 (1966).

pediatricians,

2Hessel, S, and Haggarty, R., General pediatrics: a study of practice in the mid-1960's, J Ped, 73:271-9 (1964). 3Mendenhall, R., Medical practice in the United States - a special report, Princeton, Robert Wood Johnson

295:1325-31 (1987).

4Schmitt, Barton D., Pediatric Telephone Advice

(1989).

16Sommerville, Ian, User interface design, Software Engineering. Reading, MA, Addison-Wesley, 1989.

17Shiffman, Richard N., Pediatric Telephone Protocols User's Manual, Arvada, HealthTek Medical Software,

Foundation, 1981.

Boston,

18Feeny,

Susan and Donovan, Ann, Changes in attitudes toward computers during implementation, in: Kingsland, L.C. (ed) Proceedings of the 13th Symposium on Computer Applications in Medical Care (1989), Washington, IEEE

Little Brown and Co. 1980. 5Brown, Jeffrey L., Telephone Medicine: A Practical Guide to Pediatric Telephone Advice, St. Louis, C.V. Mosby

(1980).

Press, pp. 807--809.

6Curtis, Peter, The practice of medicine on the telephone, J

Gen Int Med 3:294-296 (1988). 70tt, J.E., et. al., Patient management by telephone by child health associates and pediatric house officers, J. Med Educ. 49:596 (1974). 8Greitzer, Lawrence, et. al. Telephone assessment of illness by practicing pediatricians, J Ped 88:880-882

(1976).

9Verdile, Vincent P., Emergency department telephone advice, Ann Emer Med 18:278-282 (1989).

10Fosarelli,

P. and Schmitt, B., Telephone dissatisfaction in pediatric practice: Denver and Baltimore, Ped 80:28-31

(1987).

11Caplan, S. et. al., After hours telephone use in urban primary care centers, Am J Dis Child 137:878-882 (1983). 12Levy, Janice C., Development and field testing of

protociols for the management of pediatric telephone calls: Protocols for pediatric telephone calls, Ped 64:558-563 (1979). 13Fosarelli, Patricia D. The emphasis of telephone medicine in pediatric training programs, Am J Dis Child 139:555-557 (1985).

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