Emergency Department Callbacks. By Ronald A. Hellstern, MD, Chief Medical Officer, Loopback Analytics

Transcription

1 Emergency Department Callbacks By Ronald A. Hellstern, MD, Chief Medical Officer, Loopback Analytics Introduction Emergency department (ED) patient callbacks have long been known to improve ED patient satisfaction 1. A more recent study reported by The Studer Group confirms this finding 2. In his summary of the study, Quint Studer points out that of those hospitals conducting follow-up phone calls to treated and released ED patients, the lowest patient satisfaction score fell into the 70 th percentile while the callback hospitals as a group had an average score in the 90 th percentile, significantly besting the cohort average. Historically, automated call response rates have lagged behind live person call response rates by as much as a third or more, but this differential appears to be narrowing as patients adapt to automation. A recent article in American Medical News regarding office appointment reminder calls found a much smaller differential of less than 20 percent 3. Informing the patient that he/she will be called at the time of discharge significantly improves call response rates. In the ED setting, successfully completing callbacks is complicated because the staff typically makes these calls during slack time. As soon as the ED gets busy, callbacks are among the first things to be set aside. Other issues with this approach include placing calls during the morning hours when people are generally unavailable to receive them, a lack of standardization of the questions, poor documentation of call results, and inadequate question sample size. Another recent study reported in the Robert Wood Johnson Foundation e- Newsletter 4 by Dr. Tom Scaletta describes the results of a live person -- an ED callback clerk -- patient callback system in his hospital in Naperville, Illinois. 1 Shesser R, et al. The effectiveness of an organized emergency department follow- up system. Ann. Emerg. Med. Volume 15, Issue 8, pp August Dunn, L. Four Best Practices for Improving Emergency Department Results. The Studer Group Newsletter, January 25, Elliott, VS. No- show rates lowest when patients called by human being. Amednews.com, posted June 28, Scaletta T. Improving Patient Satisfaction in the Emergency Department with a Callback Clerk, RWJF e- Newsletter, June 4, 2008.

2 The summary of this study offers the observation that Press Ganey and Galluptype surveys are fine for inter-hospital benchmarking but are typically neither timely nor statistically valid for other purposes. The Naperville callback program supports the callback clerk position with off-the-shelf database and automatic dialing software. On average, one-third of all ED patients were contacted at a cost of approximately $2 per ED census visit, resulting in a total cost of around $6 per completed call. It is unclear whether the $6 estimate includes fixed costs such as office space, computer support, phone lines, etc. The hospital subsequently achieved a 95 th percentile patient satisfaction score though there was no control for other variables that might have been at play. Loopback s Emergency Department Follow-up Service Loopback Analytics in Dallas, Texas, has developed an automated Emergency Department (ED) Follow-up Service. This paper describes the results of this solution in the six months from March to September The principals involved in Loopback Analytics previously designed an appointment reminder/disease management system, giving them extensive experience with automated calling and interactive voice response (IVR) technology. In theory, automated calling should be capable of delivering almost the same patient satisfaction and other benefits as live person calling, but should do so much more reliably and at a significantly lower cost. In addition, the ability to achieve follow-up contact with the ED patient within a few days of the date of service offers significant risk management potential. Finally, due to the ease of question scripting and substitution, and the comparatively low cost of automated calling, it should be economically feasible to obtain timely, statistically valid sample sizes across a broad range of questions. The Loopback ED Follow-up Service has the following characteristics: Loopback accesses ED patient demographic and diagnostic information via a secure internet link to the hospital enterprise information system. The Loopback Reporting Dashboards and Live Person Callback Documentation modules are accessed via a browser over a secure internet link. There is no software to load on the hospital computer desktop. The product is delivered on a monthly software-as-a-service (SaaS) subscription basis.

3 Callback permission is integrated into the ED registration documents signed by the patient at intake and a flag is placed in the enterprise system to opt out those preferring not to be called. All call scripts are fully HIPAA compliant. No PHI is revealed. No calls go out until a digital primary diagnosis ICD-9 code is available in the hospital enterprise system. As a practical matter, this means that calls are typically ready to go out almost immediately after discharge in an ED with a fully implemented EMR but not until, on average, the 4 th day following the date of service in a paper-based ED. A target window of hours after date of service is the ideal time to call for risk management purposes. Demographics, EMR data and ICD codes are used to filter out a subset of patients who should not be called for a variety of reasons. The current system configuration filters out admitted patients, deceased patients, patients at the extremes of age, frequent flyers and various diagnoses such as teen pregnancy, STDs, AIDS, etc. The system uses live person recorded voice (not a computer synthesized voice) and interactive voice response technology. The number and types of questions that can be asked is fully customizable. The number of questions asked during each encounter is purposely kept to a maximum of three to minimize patient inconvenience and maximize survey completion rate with the ability to rotate questions to develop a comprehensive survey question set if so desired. The Loopback solution uses sets of related questions. Any quantitative (1-5 scale) or qualitative (open-ended question with recorded response) can be asked.

4 In the initial deployment at Loopback s alpha site, approximately 56 percent of ED patients were eligible to be called after filtering and manual opt outs with a successful patient contact rate of approximately 50 percent, meaning that the system succeeded in touching approximately 28 percent of total ED volume. This is comparable to the reported results of some live person callback programs 5 and far in excess of the 1-2 percent of patients touched by paper-based patient satisfaction survey methodologies. Completed surveys were obtained for 22 percent of the total ED volume. There is some controversy regarding the advisability of risk management calls on behalf of emergency physicians. Some experts have offered the opinion that such calls may extend the emergency physician s liability beyond the emergency department encounter, the implication being that the emergency physician can t be liable for failing to act in regard to circumstances he/she knows nothing about. Others have expressed the view that it is better to reach out to the patient, know about potential problems, prompt patient action, and retain a permanent record of the interaction. Because of this controversy, the system is designed so that it can be configured to do both risk management and service satisfaction calls simultaneously, or either one separately. If a patient responds poor or terrible with regard to how he/she is feeling today, an alert is created and automatically sent to the nurse manager at the hospital ED. Emergency department leadership is strongly encouraged to provide sufficient resources to respond to patient alerts in a timely manner, especially if risk management is a priority. Even though the benefit has not yet been quantified, calling patients who alert because they were dissatisfied appears to offer the opportunity to decompress their dissatisfaction and convince some who would otherwise be permanently lost to the system to give the ED a second chance. The system scripts purposely avoid any commitment to call for medicolegal reasons. At Loopback s alpha site, the ED clinical manager and charge nurses made a commitment to call alerting patients and another client instructed its ED physicians to call selected dissatisfied patients. It may be that a hybrid approach is used, where the automated system identifies that small subset of 5 See reference 4.

5 patients who have an immediate need or say they had a bad ED experience and then a live person calls just this select subset. Patient calls can be placed, the results of the call documented, and a follow-up customized form letter can be generated from inside the Loopback web application. The number of quantitative and qualitative questions that can be asked in an automated system is unlimited. The questions within each set are randomly rotated so that the three-primary-question limit is not exceeded. The total number of questions that can be surveyed is a function of ED volume, patient response rate and the statistical confidence level desired. Discussion The program to date has produced very interesting results. Approximately 5 percent of patients have responded with Poor or Terrible to the health status question and approximately 8 percent to one or both satisfaction questions. The majority of these patients have received a live person follow-up call though the quality of the documentation of these calls has lagged. The main reasons patients have alerted on the health status question are worsening symptomology, unrelieved pain or a newly developed concern. Just 0.7 percent of all patients contacted alerted with a circumstance that could theoretically have resulted in a bad outcome without further emergency department direction or assistance. The issues identified in this group in order of frequency were persistent nausea and vomiting, persistent fever, drug interactions, wound infections, worsening menorrhagia and missed rib fractures. Six percent of the 0.7 percent (0.04 percent) of health-status-alerting patients was subsequently admitted to the hospital. The open-ended qualitative improvement question yielded a variety of noteworthy feedback in our beta site installation: The overall ratio of positive feedback to negative feedback was 13: percent of patients contacted responded that they had such a bad experience, they would never return or recommend the facility to anyone else. 1.7 percent of patients complained about inadequate pain relief, either while waiting to be seen or post-discharge.

6 A number of physicians and nurses were identified as consistent outliers relative to specific behaviors (rudeness, roughness, etc.), and these results were directly correlated with substandard patient satisfaction scores. Several facility-related issues also were identified. Conclusions Patient acceptance of the automated calls has been remarkably positive. Negative reaction has come disproportionately from older people. However, for every negative reaction to talking to a machine, there have been 20 people who said they couldn t believe the hospital cared enough to have a system to follow up on their recovery and to routinely ask for their opinions about the quality of the service they received. Accumulating data seem to suggest that there is a positive spillover effect on paper-based patient satisfaction survey scores. The completed survey rate using this approach is much greater than the 5-7 percent paper survey completion rate typical of that type of patient satisfaction surveying. A surprising number of potential risk management issues have become evident. While most of these issues were ultimately handled resulting in successful outcomes, the potential for adverse outcomes appears to be greater than originally anticipated. Nevertheless, the ED Follow-up Service can be configured with or without the front end risk management piece. The cost of the Loopback approach is approximately one-third the cost of manual calling. The completed survey rate appears to be nearly identical to live person calling. The return on investment remains unclear largely because it is difficult to cost account the value of improved patient public relations and satisfaction or the averted bad outcome. Personally following up with those patients who say they will never return could neutralize a potentially negative public relations occurrence and could possibly result in a much more positive outcome and patient retention for a significant percentage of them. The KaiserEDU.org website 6 says that the annual system value of each U.S. patient in 2008 was $7,681. It wouldn t take too many of those patients, along with 6 KaiserEDU.org, accessed 7/23/2010.

7 their family members and friends, to completely justify the cost of the ED Follow-up Service. Automated ED callbacks may prove to be a valuable and more cost-effective approach to ED patient post-discharge risk management and service satisfaction surveying as ED personnel performance benchmarking becomes more widespread. For questions or additional information please call: Ronald A. Hellstern, MD Chief Medical Officer Loopback Analytics ron.hellstern@loopbackllc.com Loopback Analytics: Loopback Analytics provides hospitals with reliable, cost-effective, technologyenabled solutions to stay connected with patients after discharge to improve clinical outcomes, reduce readmissions, manage risk and improve patient satisfaction. Easily integrated with current hospital operations, Loopback s solutions place minimal demands on clinical and IT resources. For more information, visit