Directory Assistance for Telephone Care

Face-to-face interaction during a clinic visit is the traditional method for delivering medical care and communicating with patients. But this tradition is being challenged by a simple, inexpensive communication tool, the telephone. In this issue of JGIM, Marcantonio et al. show that the telephone can be an aid for diagnosis,¹ while Delichatsios et al. describe possible benefits from its use for assessment, triage, and treatment.² Telephone care has also been shown to improve preventive care and the management of several chronic conditions.³

Should doctors discard face-to-face medicine and move their practices to the telephone booth? On the one hand, this proposal is not as far-fetched as it might sound, at least in certain circumstances. Less than 10 years ago we had great difficulty convincing our institutional review board that it was ethical to substitute the telephone for routine follow-up.⁴ We found that substituting two telephone calls for one routine clinic visit improved several patient outcomes, reduced hospitalization, and saved money. Many now embrace the substitution of the telephone for some face-to-face visits. On the other hand, given the current lack of even a rudimentary classification scheme—one might call it a directory for telephone care—it is difficult to determine the circumstances for which telephone care is likely to be effective.

A 1997 review of 66 controlled trials of telephone care highlights how little is known. Telephone contact was usually initiated by a nurse (40%) or nonprofessional staff (20%).³ Only 3% of the reviewed studies reflected approaches initiated by a physician, and 8% by the patient. It is very difficult to determine whether the medical staff person initiating telephone contact was a regular provider of care or a new, unfamiliar provider. The nature of the contact was follow-up and counseling in 40% and telephone reminders in 33% of cases. Few controlled trials examined the impact of telephone care on access, diagnosis, or care planning. The costs of such care were seldom addressed. In brief, when examined using the simplest classification scheme of health and medical care,⁵ the emerging literature about telephone care has significant gaps.

The field of telephone care is mature enough to benefit from a classification system, a standard and succinct directory of what it is and how it works. In providing directory assistance to their readers, authors should uniformly report who initiated the contact and the familiarity of the patient with the person on the other end of the line. Authors might also provide explicit information about the patient needs and outcomes being addressed using standard nomenclature;⁶ the specific processes for which the telephone is being exploited (access, assessment, diagnosis, treatment, follow-up, or referral); and the principal nature of the interaction (simple information transfer, education, or care planning).

Let's illustrate the advantages of directory assistance for telephone care by applying this scheme to the articles by Marcantonio and Delichatsios. Marcantonio et al. do not tell us specifically who initiated the contact to the patient or whether that person was familiar with the patient. The contact was for assessment and diagnosis and involved information transfer only: it was not an interaction designed to directly impact patient outcomes. Delichatsios et al. describe outcomes of patient-initiated telephone contacts to a physician telephone coverage service. The physicians were not the patients' primary physicians. The main outcome measures were symptom relief and satisfaction with care. The telephone contact was exploited as a tool for access, assessment, diagnosis, treatment, follow-up, and referral. The nature of the interaction was simple information transfer and education (reassurance).

According to these classification criteria, the article by Delichatsios et al. clearly identifies the characteristics and value of a certain type of telephone care. The article by Marcantonio et al. imparts less information.

In summary, a standard directory of telephone care should assist readers and clinical investigators in communicating more precisely and clearly about telephone care by describing what it is and how it works. Using such a standard approach, readers can quickly determine the potential application of telephone care to their patients and settings. Investigators can use these standards to guide their choices of research questions and outcome measures.—JohnH. W asson, MD,Center for Aging, Dartmouth Medical School, Hanover, N.H.