PUBLISHED: THROMBUS Spring 2001

AUTHORS: Paul L Cervi

Consultant Haematologist

ADDRESS Basildon & Thurrock NHS Trust

Nether Mayne, Basildon, Essex SS16 5NL

CORRESPONDENCE: plcervi@pacehealthsystems.com

SUMMARY

We report on the successful use of an automated telephone system to report INR results to patients at home. We have delivered more than 13,000 INR results by phone to our active client population (9 months after introduction; 1755 evaluable patients, 51% over 70 years age). 1419 (81%) patients are using the system regularly and 336 (19%) are non-users citing inability to use the phone system (6.8% of 1755) ; pulse phone (5.2%); and hearing impairment (3.6%) as the principle explanations for non-use. Voice-mail can provide a rapid, simple, acceptable and cost-effective mechanism to transmit INR results and anticoagulant dose information to the great majority of patients who have access to and can use a touch tone phone.

RATIONALE FOR USING THE PHONE

We were unhappy with the traditional means for communicating INR results by post for the following reasons: inevitable overnight delays - delaying dose adjustment; other occasional delays - over weekends/holidays/local industrial disputes; no acknowledgement of information received and high cost. We therefore opted for an automated telephone system ahead of other forms of communication for several reasons: Nearly all patients have access to a touch tone telephone, are familiar with them and can use them. (Old style Apulse@ only telephones will not work with our service but these account for only 5% of phones in use today); Phoned information is rapid, demands immediate attention, reliable, and can be timed to influence the dose taken the same day as the blood test; The phone call can register contact with the patient so that a log of date and time of contact can be kept; It is possible to build in special messages into the telephone calls - such as what to do in case of a very high INR, non-attendance of a patient; advice when approaching treatment termination, transport arrangements etc.; Unlike letters, which are unidirectional, using the phone it is possible to interact bidirectionally with the patient, offering a repeat voice message, a confirmatory letter or a supply of laboratory request forms.

THE COMPUTERISED SYSTEM

The voice-mail server is a standard Windows NT server which is set up with high quality Dialogic telephony cards, a modem and voice-mail software (INR RELAY, PACE Health Systems Ltd) which can handle up to 30 telephone ports per server. This software imports e-mailed INR reports as standard ASCII text files through a user configurable interface, populates a voice-mail dial out database, regulates and records the activity of the server and hands back the patient telephone responses to the database to enable interactive responses such as automatic production of confirmatory letters, request forms etc. Special messages regarding dangerously high INR results, termination of treatment imminence, non-attendance of a patient, or a patient requiring domiciliary phlebotomy are incorporated when appropriate. INR report letters can be created, for example for those selected patients flagged for letters only, using a template agreed by the originating hospital. A log of hospital and patient daily activity is generated, and these logs are subsequently updated whenever further activity occurs such as a dial out, or dial in episode. Following importation of results a dial out list is generated and an automatic e-mail report is generated and sent back to the originating hospital, indicating that the importation was successful, the number of reports successfully imported, those that were rejected, and stating the reason for non importation (for example lack of a valid telephone number).

PHONING OF RESULTS

Each new result imported into the INR RELAY system will have an associated script of sound files which contain the following information in sequence: date of birth (to confirm identity); date of test; result of INR; indication whether result in high low or stable, anticoagulant to take, in what dose each day of the week, date of next test, transport arrangements. After the patient has listened to the full message, he can then be offered the opportunity to have the message repeated in full, and according to the preference of the originating hospital, he can have an offer of a confirmatory letter, a batch of request forms or other advice on how to communicate with the system by e-mail or fax. When each successful call is terminated, the patient file and the hospital files are updated and any patient requests for printed output are queued.

There are two main methods for establishing phone contact with the patient: 1) DIAL IN: The patient can phone into the system to obtain his result. If he dials from home, and caller line identification (CLI) is not suppressed, then the server will recognise the caller automatically, and the patient=s script will be automatically activated. The caller will know that the script definitely belongs to him, as he will recognise his own date of birth as a confirmatory patient identifier. If the caller is not dialling from home, or CLI is suppressed, then the script will not recognise the caller, and request the caller enter his 11 digit UK home telephone number. With DIAL IN, the caller risks getting engaged signals, has to pay for the calls, and may call before the result is available. 2) DIAL OUT: Not only is DIAL OUT completely free to the patient, it is also easier to use: In it=s simplest form, the patient or carer simply has to answer his phone at home, press any key to accept the call thus activating the script, copy down his result, dosage advice and clinic time advice and then hang up the phone. DIAL OUT has the added advantages that the system is never apparently engaged, and unlike DIAL IN, will only dial out when the result is available - resulting in fewer futile calls. Furthermore, it is actively pushing out information, rather than depending on the patient to remember to call in; this demands patient attention and improves compliance. This is especially important when the INR result is high, and the dose needs to be changed, or drug omitted. Patients with high INR=s are dialled immediately following importation, and the majority of patients with INR results within or below range, are dialled from 6pm onwards. The last patients to be phoned are those who failed to attend and are reminded to attend at the next clinic. If patients do not answer the phone on the first attempt, a further two attempts, thirty minutes apart will be made.

UPTAKE OF THE PHONE SYSTEM

Nine months after it=s introduction, 1419 of 1755 evaluable patients (81%) are using the telephone system as their sole means of acquiring results. There is a higher uptake under the age of seventy years (88% vs 77%). 336 of 1755 evaluable patients (19%) cannot use the voice-mail system giving the following reasons: technical inability to use the system 6.8%; pulse phone 5.2%; hearing impairment 3.6%; visual impairment 0.2%; no phone 0.1%; unknown 3.2%. There have been 13,000 telephoned reports in total and we know of only two episodes which resulted in significant clinical incidents: one patient misheard Athree@ for Atwo@ and presented after 7 days with an INR of 8.4, no bleeding; one patient misheard Aten@ for Atwo@ and presented to A&E with an INR of 10.5 and rectal bleeding - this patient was admitted and responded to Vitamin K and fresh frozen plasma. Following these episodes, we have upgraded our hardware and recorded new sound files repeating critical numbers, and the sound quality is now greatly enhanced. We have not had any similar incidents following the introduction of the new hardware and software. There were no episodes where the audit trail indicated that an incorrect message was transmitted to any patient.

EASE OF USE

INR RELAY has also been designed for ease of use by the laboratory Auser@ of the system. There is no attempt to take over the authority or role of the local anticoagulant service in calculating doses, clinic times or making transport arrangements. This is done at a local level, and patients in doubt about their treatment are advised to contact their local clinic for further information. INR RELAY simply relays information from source to the patient in an acceptable manner. Once the service is set up centrally, each local laboratory Auser@ simply transmits it=s daily batched reports to this service by automatic e-mail, and then awaits transmission reports (to deal with occasional problems such as patients results not imported due to inadequate information) and 24 HOUR reports (sent the next day) which summarises the previous days activity and reports on patients who have not been contacted. The system permits each local hospital to configure it=s own reports/request form templates, and to configure options appropriate to local clinic requirements. All of the activity of the server is recorded so that individual audit trails for individual patients can be traced, and individual hospital activity can be traced for workload statistics.

SECURITY

Concerns have been expressed that patient identifiable confidential information may be accessed by unauthorised users dialling or hacking into the phone system or e-mail accounts. We have not yet experienced any such unwanted interference but we are planning to encrypt e-mailed messages in future. The new technologies have much to offer in this age of communication, and the health services need to learn how to embrace them, protecting patient confidentiality at the same time.

THE FUTURE

Telephone communication of laboratory results is clearly achievable with modern technology. In our experience, it surpasses traditional methods such as the post in terms of speed, reliability, ability to interact with and interrogate the client and at lower cost. It therefore can be better utilized to guide clinical decision making in a timely fashion. We have shown that it can be used effectively with an elderly lay client population to guide their anticoagulant monitoring. E-mail will become a more popular means of results reporting in the future. However, uptake of e-mail in the UK is currently low in our anticoagulant clinic population (6% as of November, 2000). Nevertheless, we have incorporated in our system, an additional automatic e-mail and fax reports delivery module for those anticoagulant patients with an e-mail address or fax number. There will always be a sub-group of patients who, for valid reasons, will not be able to use modern technology - whether this is telephone or e-mail. Therefore no one means of communication will suit all patients and the optimal solution must offer multiple alternative solutions to the individual patient. The unique advantages of an automated telephone system are universality, speed, low cost, ease of use and the ability to interact with the caller.