Healthline – doing its share for primary care

Lesley ClarkeGeneral Manager

Ian St GeorgeMedical Director

Janet HarpSenior Nurse AdviserMcKesson New Zealand

Telephone triage – our core business

Assures consistent, quality advice and recommendations for patients with health concerns with the aim of directing the caller to the most appropriate health care provider

Healthline – overview• Nurse led service • 24x7 nationwide• Funded by Ministry of Health• Incorporates the Well Child Telephone Advice

service • Provides free access for people seeking:

– Symptom assessment– General health information– Provider information– Well Child advice

Care Enhance Call Centre software

• CeCC a clinically rigorous Triage System developed and owned by McKesson.

• The 413 guidelines in CeCC are evidence-based and peer reviewed with continued clinician feedback

• CeCC is designed to help the nurse prioritise multiple symptoms and select the appropriate guideline to complete the assessment

• The disposition is congruent with the presenting problem and the available services

• All calls are captured in CeCC as a unique call record and voice recorded for quality purposes

UtilisationHealthline and Well Child Utilisation (Annualised)

January - March 2010

0.0%2.0%4.0%6.0%8.0%

10.0%12.0%14.0%16.0%

Auckla

nd BOPCan

tC & C

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an

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Taran

aki

Waikato

Wairara

pa

Waitem

ata

West C

oast

Whang

anui

HL/WC Regional Utilisation National Utililisation

Māori utilisationMaori Callers to Healthline and Well Child Advice Service

January - March 2010

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Auck

land

Bay o

f Plen

ty

Cant

erbu

ry

Capit

al & C

oast

Coun

ties-M

anuk

au

Hawke

s Bay

Hutt

Valle

yLa

kes

MidCen

tral

Nelso

n-Mar

lboro

ugh

North

land

Otago

Sout

hland

Sout

h Ca

nterb

ury

Taira

whiti

Tara

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Waik

ato

Wair

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Wait

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Wes

t Coa

st

Wha

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ui

Maori % of pop (2006 Census) Maori % of HL/WC Callers National % of Maori pop (2006 Census)

Time of dayHealthline Calls Offered by Time of Day, Day of Week

January - March 2010

050

100150200250300350400450500

00:00

01:00

02:00

03:00

04:00

05:00

06:00

07:00

08:00

09:00

10:00

11:00

Noon

13:00

14:00

15:00

16:00

17:00

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Time of DayNu

mbe

r of C

alls

per

Hal

f Hou

r

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY

Healthline and Well Child Call Distribution by Time of Day January - March 2010

Night Hours8.0%

Weekend Hours30.5%

Business Hours33.0%

Evening Hours28.5%

Business Hours Evening Hours Night Hours Weekend Hours

Call typesCall Types: January - March 2010

Health Education9.0%

Well Child/Parenting Advice6.9%

Provider Referral5.4%

Symptomatic72.6%

Cost/Access Issue0.2%

Non-Clinical5.8%

Negative Feedback (Complaint)

0.0%

Outcomes of symptomatic callsHealthline and Well Child Triage Outcomes

January - March 2010

Contact Provider (non-urg)11.8%

Contact Provider < 24 Hrs34.2%

Urgent Care16.9%

Emergency2.7%

Self/Home Care34.3%

Most frequent symptomatic callsGuideline* %

Vomiting (Paediatric) 4.0%

Abdominal Pain / Discomfort 3.0%

Seen Doctor/Health Care Provider 2.8%

Fever (Paediatric) 2.8%

Diarrhoea (Paediatric) 2.8%

Medication Question Encounters 2.5%

Rashes, Widespread, Cause Unknown (Paediatric) 2.5%

Colds (Paediatric) 2.2%

Seen Doctor/Health Care Provider Paediatric 1.7%

Chest Pain / Discomfort 1.6%

Nausea / Vomiting 1.6%

Headache 1.6%

Immunisation Reactions (Paediatric) 1.5%

Cough (Paediatric) 1.5%

Diarrhoea / Change in Bowel Habits 1.5%

Trauma - Head (Paediatric) 1.4%

Vaginal Bleeding (Premenopausal) -- Abnormal 1.4%

Bites and Stings - Insects / Spiders 1.4%

Poisoning - Ingestion (Paediatric) 1.2%

Rash / Hives / Eruptions 1.1%

Total Top 20 Accesses 40.2%

Most frequent symptomatic calls - pandemicGuideline* %

Flu-Like Symptoms;Known/Suspected Influenza 6.0%

Vomiting (Paediatric) 4.8%

Cough (Paediatric) 3.4%

Colds (Paediatric) 3.0%

Diarrhoea (Paediatric) 2.8%

Abdominal Pain / Discomfort 2.4%

Fever (Paediatric) 2.3%

Medication Question Encounters 2.2%

Influenza (Paediatric) 2.1%

Influenza [Swine] 1.9%

Seen Doctor/Health Care Provider 1.8%

Rashes, Widespread, Cause Unknown (Paediatric) 1.7%

Seen Doctor/Health Care Provider Paediatric 1.7%

Nausea / Vomiting 1.6%

Chest Pain / Discomfort 1.5%

Diarrhoea / Change in Bowel Habits 1.5%

Headache 1.5%

Cough - Adult 1.4%

Upper Respiratory Tract Infections / Colds 1.3%

Sore Throat / Hoarseness 1.3%

Total Top 20 Accesses 46.2%

Most frequent information callsMost Frequently-Accessed HIL Topics: Healthline %

Temperature Fever Self Care 7.5%

Risk Of Lower Intent 4.2%

Temperature Range And Thermometers 3.6%

Chickenpox 3.3%

Constipation Infants Toddlers 2.2%

Hand Foot And Mouth Disease 1.9%

Diarrhoea Selfcare 1.9%

Vomiting Selfcare 1.6%

Pregnancy Tests. 1.3%

Emergency Contraception 1.3%

School Exclusion 1.2%

Tetanus. 1.1%

Cough Flu Self Cares 1.0%

Scabies. 1.0%

Depo Provera 0.8%

Giving Oral Medication 0.8%

Colds 0.8%

Herpes Zoster And Herpes Zoster In Pregnancy (Shingles) 0.8%

Measles. 0.7%

Combined Oral Contraceptive Pill 0.7%

Top 20% of total 37.6%

Most frequent information calls - pandemicMost Frequently-Accessed HIL Topics: Healthline %

Swine Flu H1N1 influenza 10.9%

Temperature fever Self Care 8.5%

Swine Flu in USA and Mexico Travellers Advice 7.1%

Temperature Range and Thermometers 3.4%

Tamiflu 3.2%

Chickenpox 2.9%

Risk of lower intent 2.7%

Novel Influenza A H1N1 [Swine flu] 2.6%

Constipation Infants Toddlers 2.1%

Vomiting selfcare 2.1%

Diarrhoea selfcare 1.9%

Cough Flu Self Cares 1.9%

Ministry of Education Swine Influenza Update 1.5%

Colds 1.4%

Pregnancy tests. 0.9%

School Exclusion 0.9%

Influenza A [H1N1] Advice for Health Professionals 0.9%

Emergency Contraception 0.9%

Croup 0.9%

Scabies. 0.8%

Top 20% of total 57.5%

Doing its share: H1N1 pandemic

H1N1 pandemic timeline• 26 April News: 10 students returning from Mexico have tested positive for

swine flu. • 27 April Code Yellow: Ministry of Health begins containment activities.

People who had travelled to Mexico or the US in the last fortnight advised to contact Healthline generating a 60% increase in calls.

• 30 April NZ has 16 confirmed cases, 104 suspected and 111 isolated.• 13 June Two confirmed cases with no links to travel indicate community

transmission. Containment strategies continued. General public advised to ring Healthline for information and health advice.

• 16 June Increasing number of school closures. People advised to stay at home if unwell and phone Healthline or General Practitioner.

• 19 June community transmission widespread in Auckland, Wellington and Christchurch.

• 4 July First 3 NZ deaths associated with swine flu. Calls to Healthline peak on 6 July with 3,622 calls offered.

• 31 August 17 deaths• 30 September 18 deaths

GP consultations during the pandemic

HL calls during the pandemicInfluenza Like Illness Calls to Healthline

0

500

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4500W

eek

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Num

ber o

f ILI

Gui

delin

es

2008 2009

May June July August September

Callflow

Calls to Healthline0800 611 116

4If you are a health

professional

1No symptoms but

seeking flu info

2Any symptoms

3Well Child call (no symptoms)

Telecom cloud

Default Healthline

HealthlineAnswered by HL nurse:• normal triage, or• if no symptoms told to“phone back and press 1”for flu info

Not answered (overload)additional message:•flu symptoms – call back and press 1 to talk to an operator, or• other symptoms – queue for Healthline

Well Child line or PlunketLine

Recorded message for public

Press 0 forWanganui call centre (case def; Q&A script)

If symptomaticcall backand press 2 (but if long delays, advise “phone doctor”)

Recorded message for health profs (including DHB contact details)

Press 0 for Operator

Press options:5

Workplace orschool info

Recorded message for work-places and schools

Press 0 for Operator

Call numbersHealthline and Well Child Calls Offered/Handled: 15 Month Trend

40000

5000060000

7000080000

90000100000

110000120000

130000

Jan-Mar 09 Apr-Jun 09 Jul-Sep 09 Oct-Dec 09 Jan-Mar 10

Calls Offered Calls Handled

Doing its share: right care, right time, right place

People with symptoms may need advice on the right place and the right time to seek care: 100 callers intending (A) were triaged to…

0

5

10

15

20

25

30

35

40

45

50

111 ED Urgent GP Nonurgent care Selfcare

111

ED

Urgent GP

NonurgentcareSelfcare

A

Effect on an urban ED

Transferring ED calls to Healthline did not decrease the number of presentations to Christchurch Emergency Department, but did decrease the number of phone callers seeking advice, to the extent that one fulltime nurse was freed for other duties

-- Graber DJ, O’Donovan P, Ardagh MW, St George IM.NZ Med.J. 2003. 116 (1177): 495-501).

Effect on a rural practice

Telephone triage reduced out-of-hours work for country doctors– Fewer phone calls– Probably fewer patients to see– Safe and reliable

-- St George IM, Cullen M, Branney M, Hogan M, Duncan L. NZ Family Physician, 2003. 30: 95-99.

Do primary care doctors agree with our advice?

-- St George IM, Cullen M. Branney M. Healthline: do primary care doctors agree with the advice? NZMedJ, 2005; 118 (1224).

•Three primary care specialists examined 90 calls – blind to HL endpoint

• Endpoints advised by the three doctors varied: crude percentage agreement between the highest and lowest was only 51% (Cohen’s K 0.43)

• We compared the median doctor- advised endpoint for each case with the endpoints reached by the Healthline nurses: crude percentage agreement was 70% (Cohen’s K = 0.78)

•Cohen’s Kappa 0.61 - 0.80 = Substantial Agreement

Doing its share: improving access

Ethnicity

• NZ European 70.2%* (75.8)†• Maori 17.4% (11.8)• Samoan 2.8% (1.8)• Indian 2.1% (1.9)• Chinese 1.0% (1.8)

* = Healthline 2010† = National Primary Medical Care (NatMedCa) GP survey 2004

HL use by older people….1

Healthline and Well Child Adv ice Serv ice : Patient/Caller Demographics

(n= 76927 )

0-14 yrs37.4%

15-24 yrs15.4%

Over 656.1%

25-64 yrs41.1%

HL use by older people….2Fig.3: distribution of patient-initiated GP

encounters (WaiMedCa ) and calls (Healthline) by age group

0

5

10

15

20

25

30

35

<1 1-4 5-14 15-24 25-44 45-64 65-74 75+

age group

perc

ent

WaiMedCaHealthline

Deprivation levels

-- St George IM, Cullen MJ, Branney M. The deprivation profile and ethnicity of Healthline callers. NZ Fam Phys 2006; 33 (6): 386-389.

Fig.1: Percent of callers to Healthline in each deprivation decile, compared with percent of

the New Zealand population in each decile

0

2

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HealthlineNew Zealand

Cellphone callers

-- St George IM, Cullen MJ, Harp J. Cellphone callers to a triage and advice line may have high health needs. Submitted to Australian & NZ Journal of Public Health 2009.

Fig.1. Cellphone users as percent of all callers, May 2005 to February 2009

0%

5%

10%

15%

20%

25%

1 13 25 37

Months May 05 to Feb 09

Perc

ent

Cellphone calls

Cellphone callers: 2

0

5

10

15

20

25

30

1 2 3 4 5 6 7 8 9 10

Deprivation index

Perc

ent

Cellphone usersLandline users

Fig.2: percent of cellphone callers (n = 132) in each NZDep06 decile of deprivation, compared with percent of landline callers (n = 873) in each decile.

Healthline’s original aims: achieved • Social equity: those who perceived

barriers to seeking help would be able to do so: especially Māori, Tagata Pasifika, socioeconomically deprived, elders….

• Economic: resources would be saved by demand management: directing people to the right place at the right time.

Doing its share: Quality & safety

Transparency

• Comprehensive data collection• Quarterly reports• Frequent conference presentations• Articles in popular health press• Studies published in peer-reviewed

literature

1. St George IM, Cullen MJ. The Healthline pilot: call centre triage in New Zealand. N Z Med J. 2001 Sep 28;114(1140):429-30.

2. St George IM. The holidays at Healthline. NZ Fam Phys 2002; 29: 123.3. St George IM, Branney M, Horo-Gregory W, Duncan L, Cullen M. Maori callers to a telephone triage service. NZ Fam

Phys, 2003; 30: 261-263.4. St George IM, Cullen M. Crisis calls to Healthline. N Z Fam Phys, 2003. 30: 40-41.5. Graber DJ, O’Donovan P, Ardagh MW, St George IM. A telephone advice line does not decrease the number of

presentations to Christchurch Emergency Department, but does decrease the number of phone callers seeking advice. NZ Med.J. 2003. 116 (1177): 495-501.

6. St George IM, Cullen M, Branney M, Hogan M, Duncan L. Telephone triage reduces out-of-hours work for country doctors. NZ Family Physician, 2003. 30: 95-99.

7. St George IM, Cullen M, Branney M. A primary care demand management pilot in New Zealand: telephone triage using symptom-based algorithms. Asia-Pacific Family Medicine 2003; 2 (3): 153-156.

8. St George IM. Cullen M, Branney M. How well does telephone triage meet the needs of older people? NZ Family Physician 2005; 32: 94-97.

9. St George IM, Cullen M. Branney M. Healthline: do primary care doctors agree with the advice? NZMedJ, 2005; 118 (1224): http://www.nzma.org.nz/journal/118-1224/1693/.

10. St George IM, Cullen MJ, Branney M. The deprivation profile and ethnicity of Healthline callers. NZ Fam Phys 2006; 33 (6): 386-389.

11. St George IM, Cullen M, Wilson A, Wilson F, Dolan B, McGeorge P. The Mental Health Line. NZ Family Physician, 2006; 33 (5): 336-7.

12. St George IM, Cullen MJ, Branney M. What part does a national health call centre play in an integrated primary care service? NZ Med J 2007; 120 (Feb).

13. St George IM, Matthew Cullen, Louise Gardiner, Georgia Karabatsos, Joseph Ng, Andrew Patterson, Andrew Wilson. Universal telenursing triage in Australia and New Zealand: a new primary health service. Australian Family Physician, 2007; Vol 37, (6) 476–479.

14. St George IM, Julie Baker, Georgia Karabatsos, Richard Brimble, Andrew Wilson, Matthew Cullen. How safe is telenursing from home? Collegian: Journal of the Royal College of Nursing Australia 2009; Vol. 16 (3): 119-123

15. St George IM, Cullen MJ, Harp J. Cellphone callers to a triage and advice line may have high health needs. Submitted to Australian & NZ Journal of Public Health 2009.

16. St George IM, Harp J. Telenursing in New Zealand. A chapter in Telenursing 2009. In press.

Clinical governance principles• Clinical effectiveness - correct use of up to date

protocols, algorithms, guidelines and procedures.

• Professional development – continuing learning; employee satisfaction; credentialing; research; publications and presentations; transparency.

• Clinical risks - adverse events monitoring including critical incident management; clinical audits.

• Customer complaint and compliment processes.

Doing its share: but wait – there’s more

OpportunitiesTelenursing is more than Healthline;

– Syndromic surveillance– Mental Health Line– MeNZB Line– Taranaki pilot - after hours enhanced services– Disease Management – telephone coaching– Secondary triage for 111– Pandemic and other public health situations– McKesson@Home workforce

Telenursing in Australia

• HealthDirect triage and advice; • HealthInfo information and health policy; • SouthWest24 mental health services; • Residential Care Line; • Sexual Assault Referral Centre Crisis Line; • Drug Cautioning Line;• Health Incident Lines (public health emergency lines as required, e.g. SARS

line); • PEP (post-exposure prophylaxis for HIV). • Secondary triage for the St John Ambulance; • Chest pain program for insured patients; • Outpatient bookings (an appointment, reminder and tracking system); • Surgical patient follow up.• Greater Murray Access Line, • gambling line, • chronic disease management.

Doing its share for primary care• High quality evidence-based advice

– Experienced registered nurses using robust decision support software

– More than 400 guidelines ensure clinical safety and consistency.– The clinical guidelines assess the urgency of the caller’s

symptoms, so nurses can advise where and when to go for help.– Guidelines and procedures are continuously monitored and

updated.– Well established clinical governance framework; ISO 9001

certified– All calls are captured in CECC and are voice recorded for quality

purposes. The service is transparent and accountable.

Doing its share for primary care• Health providers and health sector

– Free, high quality, evidence-based advice available to your patients 24/7.

– After hours call diversion– Significant role in pandemic and health alert situations, such as

national pandemics reducing the burden on other health services.

– Health and communicable disease surveillance, by collecting calldata for analysis of specific health events e.g. Influenza like illness (ILI) monitoring data, measles outbreaks.

Doing its share for primary care• Your patients

– Access to triage and health advice 24/7, including for those in isolated areas or on a lower income.

– Free from landline or cell phone– Registered nurses to direct callers to GPs, emergency services

or support callers to self-care, where appropriate.– Information on the location and availability of health care

services including after hours primary health care. – Links to other services so callers have access to a range of

health and wellness information. – Call backs to check on progress.

Doing its share for primary care• Performance assured

– Healthline handles over 350,000 calls per year, helping to reduce demand on other services

– More than 80 percent of calls are answered within 20 seconds– Less than 5% of calls unanswered – Low level of complaints (one per 7500 calls) – Able to reach groups with greater needs, including Maori and

Pacific populations – High levels of customer satisfaction.

nzherald.co.nz - Tuesday March 9, 2010

Little Emily Cotton is smiling again and her mother, Susan, is singing the praises of the Healthline service after her call produced the right answer.

… any questions?