Electronic (HTML) Telephone Triage Protocols & AHLTA

BACKGROUND: MHS Registered Nurses managed 2.9 million telephone consults in FY 2012. Based on experience, the average telephone consult takes 10 minutes. Approximately, 3 minutes, is spent typing out relevant signs and symptoms or home care advice. This results in 146,784 hours or 6,116 days or 14 years that MHS RNs spend simply typing information into the electronic health record (EHR). We can do better! We can reduce the time it takes for documentation, reduce the time talking on the phone, and improve patient care. More importantly we can implement the change right now with our current Electronic Health Record (AHLTA).

CURRENT STATE: For the majority of MTFs in the MHS there are several paperback triage books being used by nurses to provide guidance. In some MTFs these books may be several years old and outdated. The quality of these protocols can vary based on the training level of the author; some are written by nurses while others are written by physicians. Bottom-line, there are no standardized nursing telephone triage protocols in the MHS. In addition, and in order to save time, RNs may only cite a page and protocol used in their documentation. This means anyone else reviewing the chart will not know what specific guidance was giving to the patient, unless they happen to have that book in front of them.

FUTURE STATE: A few MTFs in the MHS have implemented the use of an electronic (HTML formatted) version of telephone triage protocols. These standardized protocols were authored by two physicians and are internationally recognized and evidenced based. The protocols work like a desktop electronic reference and allow error proof “cut and paste” into an AHLTA note. RNs using these HTML formatted protocols report less time typing and increased quality of documentation. As secure messaging rolls out, the home care advice can be pasted into a message and sent directly to the patient. While the DoD nursing advice line contract was recently awarded, RNs in the MTF clinics will always have to manage symptomatic calls … it’s a critical role … it’s what we do. Ideally, telephone triage protocols would be embedded into the electronic health record, but that solution will have to wait for additional improvement in the EHR. Nurses need a solution today – so we can better care for our patients today.

IMPLEMENTATION & ROI: This initiative would implement standardized HTML formatted telephone triage protocols across the MHS. Assuming there are 2400 RNs in the MHS (known 800 in AF x 3 for tri-service), the initial investment would be $96K. (In comparison, purchasing text books for the same number of RNs would cost $432K). Projecting the number of telephone consults remains stable and approximately 15% of telephone consults are symptom based and time saved per telephone consult is 5 minutes, than MHS could save 37K nursing hours/year.

RESULTS: Each pillar of quadruple aim is enhanced with this initiative. RN documentation, such as home care advice, can be easily adapted to patient’s encounter and inputted into secure messaging for patient’s direct access. Providers and ancillary staff will be able to review specific guidance and follow up accordingly – resulting in enhanced Experience of Care for the customer. Population Health improves as more patients are thoroughly educated on what actions they can take for self-care and take ownership of their medical care. Readiness improves as RNs are able to spend less time on the phone and patient access improves. Finally, Per Capita Cost improves as all MHS MTF RNs have more cost effective tools at their fingertips and communicate more efficiently with their patients.

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