Medical network management system and process5764923Abstract In a medical network management system (NMS) (20), health plan beneficiaries access a team of health care professionals over the telephone to help them assess their health needs and select appropriate care. The NMS (20) has a patient assessment component (22). The patient assessment component consists of a set of information tools which are used by health care professionals to assess patient conditions and assist in the selection of health care services and to help patients find appropriate care at the appropriate time. The tools include a comprehensive, automated set of proprietary assessment algorithms (26) which are based on branched chain algorithms utilizing Bayes theorem. These unique, clinical tools enable a trained nurse or other health care professional to sort patients into different risk categories, safely and effectively without requiring a medical diagnosis. Patients can then be guided to an appropriate level and type of care for their problem(s) based on their level of risk and set of potential needs. Claims What is claimed is: Description BACKGROUND OF THE INVENTION
TABLE 1
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Clinical Causes of Back Pain
Emergent (e.g., dissecting aortic aneurism)
10
Non-musculo-skeletal (e.g., bladder infection)
35
Musculo-skeletal, potentially benefits from medical care
65
Musculo-skeletal, self-limiting,self-correcting, little
890
benefit from medical care
Total 1000
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Through the process of asking questions and sorting patients by risk categories, the striking results displayed in Table 2 below can safely be achieved.
TABLE 2
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Source of Probable Treatment of 1000 Patients With
Acute Lower Back Pain
UNDER
INITIAL FEE FOR UNDER UNDER
PROVIDER SERVICE MEDICAID NMS
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Emergency Department
100 300 30
Provider Appointment,
700 600 350
all other causes
Self Care 200 100 620
Total Patients
1000 1000 1000
Total Charges (in 000's)
$67 $63 $25.5 - FFS**
$19.4 - Medicaid
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**Note that FFS stands for fee for service and these two numbers represen
the costs incurred when using the NMS to provide access for either fee fo
service or Medicaid patients.
When any of the algorithms indicate that medical intervention is appropriate for a given patient, the nurse will then use the second major component of the NMS, which is described below, to assist that patient in selecting an appropriate, individual provider. Provider Information Component 24 The second major component of the system consists of a proprietary relational database which contains the information necessary to effectively differentiate the various providers participating in a given network and to manage the patient flow into their practices. This system component enables the nurse to help patients select an individual doctor, clinic, or hospital; an appropriate provider of the services required to meet their needs. The patient assessment component 22 and the provider information component 24 are linked at 28 by provider codes, which identify by standard procedure billing codes, what procedures the different providers perform in the normal course of their practice. The link 28 further includes patient information, such as sex, age, zip code, health plan and other patient information useful for matching a patient to a provider. Data describing areas of clinical expertise and the practice in general, is collected from each provider. This information is monitored and updated regularly. It can also be augmented by relevant information from other sources such as claims data and can contain items such as procedural frequency or clinical outcomes. Medical Network Management Process Nurses search the information using the criteria necessary to meet specific patient needs as identified through the assessment process. An example of the assessment process is provided in FIG. 2. The process begins when the patient calls or sees a nurse utilizing the NMS 11 at 40. Patient information is gathered and eligibility is confirmed at 42 by accessing data from a patient chart at 44. A determination is then made at 46 whether the patient requires medical intervention, using the algorithms 26. If medical intervention is not required, home care instructions are provided at 48 and a follow-up call is scheduled at 50. In follow-up a determination is made at 52 whether the problem has been resolved safely. If not, another determination is made at 46 whether medical intervention is required. At either stage, if the determination at 46 is that medical intervention is required, a determination is then made of what level and type of care is needed at 54. The most appropriate source and timing of the care is made at 56. A determination is made at 58, usually by the caregiver, whether the problem has been safely resolved. If not, another determination is made at 46 whether medical intervention is require At either 52 or 58, when it is determined that the problem has been resolved safely, feedback and analysis to the NMS 11 is provided at 60. To better understand provider selection, again consider the 1000 patients with lower back pain. Without the NMS 11 to help guide patients, many individuals who have a self-correcting condition will see a doctor and begin to receive care that in most cases will not have medical benefit. Many expensive CT or MRI scans may be performed to try to determine the cause of pain which, in most cases, will go away on its own with a proper self-care regimen. Many patients will also receive treatment from a provider who does not necessarily focus on the management of lower back pain. The result is often lower quality care than can be predictably delivered by a doctor who focuses in this area. For example, if the initial consultation is with any surgical specialist, the statistical likelihood of surgical intervention is two to three times that occurring when care begins with a non-surgical provider . . . and with no improvement in long term outcome and at much higher costs. The following table depicts the potential impact from the Provider Access Service on the utilization of medical services by the 1000 lower back pain patients described above, in addition to the initial doctor visit.
TABLE 3
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Distribution of Additional Medical Care
UNDER
ADDITIONAL FEE FOR UNDER UNDER
CARE SERVICE MEDICAID IAS
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Diagnostic Tests
600 720 150
Medical Treatment
280 270 70
Surgical Treatment
120 180 80
Total Additional
$977 $930 $553 - FFS**
Care (in 000's) $395 - Medicaid
Total Care $1,044 $993 $578 - FFS
(in 000's) $414 - Medicaid
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**Note that savings from the NMS will be even greater over time as
information is added which identifies providers who use less invasive,
less costly procedures or ones who achieve more favorable, less costly
outcomes.
Inefficiency such as that depicted in the preceding examples of the treatment of lower back pain, is endemic in American health care. It exists largely because of the uninformed and ineffective matching of patient need with provider services. To date, efforts at managing care have not been able to eliminate much of this inefficiency because of the non-integrated approach they have taken. Research abounds which indicates that the opportunity for improvement in the current delivery of care through the NMS is significant. Rand Corporation studies suggest that over 1/2 of all procedures currently performed each year may have no discernable medical benefit. In the National Center for Health Statistics' surveys of practicing doctors by specialty, providers themselves estimated that approximately 1/2 of all ambulatory care office visits were not medically necessary. National experts in Medicaid health care patterns state that over 1/2 of the emergency room use by Medicaid recipients nationally, is inappropriate. The patient assessment component 22 and the provider information component 24 of the NMS 11 can be used or sold separately or together as part of the NMS 11. The algorithms 26 provide a mechanism by which one can examine the presence of one or more concerns or etiologies as the underlying cause of patient symptoms. Each yes/no stem question must be answered yes or no and leads to another question or action recommendation or transfer to another algorithm Bayes Theorem provides the underlying rationale as to why this process works. The nodes are not all related to each other, nor are they probabilistically dependent on each other. If a stem question, high sensitivity, is answered yes, then in many cases and in general, questions of higher specificity are asked to determine more accurately the appropriate action or intervention which should take place, by whom, and in what time frame. The algorithms sort patients by "risk", in that, if you cannot eliminate with an acceptable level or degree of risk the potential that a significant concern or etiology is present, then an action or recommendation appropriate for that concern or etiology is arrived at by the system. The actions and endpoints of the algorithms are of a limited number and variety, and are intended to represent generally the categories of options available to a patient within a typical health care system. In the cases where an interaction by another "provider" is recommended, the system also presents specifications describing an "appropriate" provider. These specifications can be any number of items, including clinical codes, procedural codes, doctor specialty, or even a specific provider or clinic. If the algorithms are not attached to a provider database, then these specifications would be available as general guidelines for the appropriate next recommended intervention. If a provider database is attached, data from the call and the algorithm will "link" into the provider selection process, as indicated at 28. Here, the specifications already determined, including the patient health plan, sex, age and any relevant clinical codes and/or procedure codes are carried across into the provider selection process. The clinical codes are used in a unique manner in the process. The participating providers provide information about themselves, their practices, and the clinical services they offer. This information is collected with NMS forms, augmented by any other sources of data available, and loaded into a database. This information represents the "supply" of services then available to meet the "demand" of patient needs within a given group of patients and providers. Another way to express this unique application of the clinical codes is that they allow the provider to represent the services they provide, and thus describe the profile of the patient/patient problems they treat or do not treat. This use of such clinical codes in a "prospective" manner to try to manage the appropriate matching of demand and supply--patient need with provider services--within a health care system is unique. Many of these codes were developed and historically have been used to provide retrospective information about what was done. This information is often used to bill for services and account for patient problems. Another feature of the system and process is that the clinical or procedural codes extend to the health plan or insurer or whoever manages or controls the provider network the ability to control the specific services available from specific providers. Over time and with experience, the health plan manager can then retrospectively go back into the database and change the "care paths" allowable or available to different patients to continue refining and improving the quality of care provided. The clinical codes used in the system and process are based on the following classification systems: ICD.9.CM, provided in "International Classification of Diseases," 9th. Revision, 3rd. Edition, with Clinical Modification. DSM-III-R, provided in "Diagnostic and Statistical Manual of Mental Disorders," 3rd. Edition, Revised (Washington, American Psychiatric Association, 1987). The procedural codes used in the system and process are based on the following classification systems: CPT-4, provided in "Physicians Current Procedural Terminology," Fourth Edition, developed and revised by Department of Coding and Nomenclature, American Medical Association. CDT, provided in "Current Dental Terminology," First Edition, 1990-1995, American Dental Association. Additional clinical codes which both represent services offered or provided by providers and needed by patients are used in the system and process. Typically, these additional codes describe clinically what might be wrong with the patient, what might be needed by the patient, what the provider treats, does or has available (equipment). Not everything is included in the above published coding schemes. The system and process further provides a "call processing" mechanism, described more fully below, which assists the user in handling a patient interaction and making appropriate use of the algorithms and provider database. This mechanism records every "keystroke", including all free text comments, so that records of all calls are retained. The system can generate reports describing the use of the system and its components, so that it can be improved over time. The architecture of the system is flexible. Most components, including algorithms, self-care instructions and provider codes can be easily modified without altering the underlying computer code. The NMS Algorithms The purpose of the yes-no branched chain algorithm logic of the NMS system and process is neither to diagnose nor to treat medical conditions. Rather, the algorithms logically sort a population of individuals who have, by telephone, identified themselves or someone else as possibly ill, usually because of a new sign or symptom which the caller feels is possibly due to an illness or to an injury, and who are seeking advice on what to "do next." The NMS algorithm logic uses the principles of Bayes Theorem to identify some sub-populations whose risk of serious illness or injury is so low as to make home care an appropriate choice and to, by exclusion, identify other populations whose risk of serious illness or injury is high enough to warrant provider evaluation. Further, the NMS algorithm logic is able to identify from among those populations requiring provider evaluation various sub-populations whose requirement for provider evaluation vary in their time urgency and the required medical service capability of the provider. The NMS algorithm logic is also able to identify for those populations requiring provider evaluation the essential provider medical skill set required for an efficient and effective evaluation of each subpopulation. Coupled with the NMS provider matching logic, this allows NMS to determine for each caller: whether provider evaluation is needed; if provider evaluation is needed, how soon it is needed; if provider evaluation is needed, what constitutes the requisite skill set a provider needs to be effective and efficient in caring for the conditions likely to be causing the sign or symptom prompting the telephone call; which providers have that requisite skill set and are available in the required time-frame. Bayes Theorem describes how, when individual members of a population already at a low pre-test possibility for a condition have a negative result to a test of high sensitivity for the presence of that condition, the post-test probability of that condition is extremely low. Bayes Theorem also describes how, when individual members of a population at low pre-test possibility for a condition have a positive result to a test of high sensitivity for the presence of that condition, the post-test probability of that condition is not (clinically) significantly higher than was the pre-test probability. The NMS system uses complaint-specific algorithms to determine by telephone the appropriate "next medical step" for a caller. Review of medical statistics shows that, in the United States, almost regardless of the nature of the sign or symptom, serious illness/injury is at very low pre-test probability: of ambulatory patients evaluated in physician's offices, far less than one percent require hospital admission; of callers summoning dispatch of ambulances via 911 telephone, a small percentage are admitted to hospital; of ambulatory patients evaluated in hospital Emergency Departments, less than 5% require hospital admission. The NMS algorithms use as "tests" various yes-no questions selected by clinical experts on the basis of their high sensitivity for the presence of diseases/conditions which, if not evaluated by providers, may significantly harm the caller. The algorithms apply these highly sensitive "tests" to caller populations already at low pre-test probability of serious illness/injury, as described above. Thus, Bayes Theorem describes the clinical implications of both "positive" and "negative" "test results" in the NMS system: Callers with negative results (responding with "no" answers) to these tests (yes-no questions) have an extremely low post-test probability of the illness/injury under consideration. Callers with positive results (responding with "yes" answers) to these tests (yes-no questions) have a post-test probability of the illness/injury under consideration that is not (clinically) significantly different than before the "test" was performed, i.e., the test cannot sufficiently lower the probabilities. For a population at low pre-test probability of specific illnesses/injuries, the NMS algorithms perform one or several tests of high sensitivity for a specific illness/injury. The NMS algorithms then iteratively repeat that testing process by applying tests highly sensitive for each condition which must be eliminated. The algorithms are deliberately designed to try to eliminate the possible presence of illnesses/injuries of extreme medical time-urgency and to test subsequently for less time urgent illnesses/injuries. The algorithm logic considers members of a population identified by this iterative process as being at extremely low post-test probability for all conditions which must be detected as suited to self-care. The algorithm logic considers as requiring provider evaluation those members of a population identified by this iterative process as having positive "test" results which do not allow sufficient reduction of the probability of an illness/condition. The time urgency for that required provider evaluation is a clinically established derivative of the nature of the illness/injury whose probability has not been (clinically) sufficiently reduced by the testing procedure. Further details on the applicability of Bayes Theorem to the NMS algorithms are provided in FIG. 3. Assume that, for a population exhibiting sign/symptom "A", clinical expertise establishes that: if the established probabilities of illness/injury T, U, V, or W exceed "low," provider evaluation is medically appropriate; if the established probabilities of illness/injury T, U, V or W are each "extremely low" or less, self-care is medically appropriate; questions T', U', V' and W' in algorithm 80 at 82, 84, 86 and 88 respectively are each highly sensitive for illness/injury T, U, V, and W respectively. Then, the algorithm 80 produces the indicated five sub-populations: Population T" at 90, where the probability of illness/injury T is greater than "low" and whose members therefore require provider evaluation for illness/injury T; Population U" at 92, where the probability of illness/injury U is greater than "low" and whose members therefore require provider evaluation for illness/injury U; Population V" at 94, where the probability of illness/injury V is greater than "low" and whose members therefore require provider evaluation for illness/injury V; Population W" at 96, where the probability of illness/injury W is greater than "low" and whose members therefore require provider evaluation for illness/injury W; Population Z" at 98, where the probability of illness/injury T, U, V, or W is extremely low, and, therefore, for whose members self care is appropriate. Attached as an appendix to this application is a representative algorithm for the NMS system, covering adult back pain. FIGS. 4A-4E illustrate the branched chain logic for this algorithm. Each of the NMS algorithms has four components: The Cover Sheet The cover sheet provides a variety of information about the algorithm, including conditions considered, estimated action point distribution, and excluded conditions. The algorithm cover sheet is intended to provide a comprehensive overview of the algorithm. The key uses of the information are as follows: Algorithm Selection The fields "Algorithm Name," "Category," "Keywords" and "Similar Complaints" are all used to assist the nurse during the automated process of selecting an appropriate algorithm. "Opening Screen" In the NMS system, once a nurse has selected a given algorithm, an opening screen appears, which provides a brief description of the algorithm, including the following fields: "What Does it Do?" Algorithm Road Map (intended to give nurse a sense of the length of the algorithm) Excluded Populations Relevant Medical Risk Factors Utilization Management Each and every algorithm as an "Anticipated Call Distribution." This represents the best judgement of an experienced medical staff based on their cumulative experience and will serve as the baseline for evaluating the efficiency of the algorithm and will be updated with the availability of empirical data. Clinical Overview The "Areas of Inefficiency/Anticipated Economic Impact" provides a clinical synopsis of the algorithm, essentially representing a differential diagnosis of the presenting complaint, together with estimates of its prevalence, severity, and recommended level of intervention. The Logic The algorithms' formal logic is branch-chained and binary. (An unsure answer has information to help determine whether to defer to yes or no.) Its use by nurses standardizes their evaluation while allowing the nurse to add his/her professional expertise to the information gathered (but not to idiosyncratically replace the formal logic) to "sort" best a patient's problem. The logic "sorts" to several defined "action points" whose definitions are central to the process. The algorithm logic lays out the questions in the order they will be presented to the nurse by the system. The algorithms represent branched chain logic, with the most sensitive questions being asked first, moving on, in response to positive answers, to more specific questions to identify more specifically timing and type of appropriate care. The numbering of the nodes or boxes in FIGS. 4A-4E corresponds with the corresponding points in the node text of the appendix. The NMS system includes a unique Algorithm Editor, which allows a clinician, rather than a programmer, to create and/or modify an algorithm without having to write code. FIGS. 4A-4E and the corresponding node text of the appendix is output from that tool. The Node Text The node text is the "why" behind the algorithm logic. For each yes-no branch and each action point, the algorithm authors have written their medical explanation of the logic in standardized format. This also includes scripted questions for the nurses to use, should they so wish. The algorithm node text is the supporting data for each and every question and end point in the NMS system. Most of this information is visible to the nurse as he/she "traverses" a given algorithm. As with the algorithm logic, any text changes in the node text can also be modified by a medical administrator through the Algorithm Editor, without writing code. This allows knowledgeable users of the NMS system essentially to create their own "customized" algorithms, using those provided with the system as a base. The following is a brief description of the categories within the node text of the appendix. An understanding of the action point definitions is central to evaluating the algorithms. They are: INITIATE EMERGENCY PROCEDURES The NMS nurse will connect the caller to the local EMS Dispatcher without further delay. (Used when there is reasonable reason to suppose the need for on-site and en-route care beyond the capabilities of the typical caregiver.) SPEAK TO NMS PROVIDER The NMS nurse will connect the caller to a physician who works with the NMS system to complete the triage encounter. (Used when there exists a possible need for EMS Dispatch, but when a physician interview may identify more appropriate actions, i.e., cuts down on the "false positive" EMS Dispatches.) URGENT CARE The patient needs care now (e.g., a deep and dirty laceration), but does not need EMS care on site or en route. While urgent care can be delivered in hospital-based emergency departments, free standing emergency clinics, and doctors' offices, it does require that the site be open at the time the care is needed, since the care cannot be delayed. SPEAK TO PROVIDER-SORTING The NMS nurse will assist the caller in speaking to a physician whose role will be to determine the appropriate next step in the patient's care. This physician can be the patient's primary care physician, the physician "covering for" the patient's primary care physician, or a physician in the employ of the patient's insurance carrier. (Note: The NMS algorithm logic can designate that this contact occur either "NOW" or "LATER". The "NOW" designation means that the caller should speak to the physician as soon as possible; the "LATER" designation means that the contact can be delayed for up to 4 hours. SPEAK TO PROVIDER-TREATMENT The NMS nurse will assist the caller in speaking to a physician whose role will be to decide whether appropriate care can be initiated by telephone with follow up care by appointment. This physician can be the patient's primary care physician, the physician "covering for" the patient's primary care physician, or a physician in the employ of the patient's insurance carrier. EARLY ILLNESS APPOINTMENT The NMS nurse will assist the caller in establishing an appointment with an appropriate provider "the next time that office is open". Most often this will be an appointment "later today" or "tomorrow"; however, a call late Friday evening might result in an appointment Monday morning. ROUTINE ILLNESS APPOINTMENT The NMS nurse will assist the caller in establishing a "routine" appointment with an appropriate provider. The standard is that the appointment will be no later than two weeks from the date of the call. SELF CARE The NMS nurse will instruct the caller in understanding why self care is the most appropriate "next step", explaining the steps of self care, "granting call-back permission" to the caller, and scheduling any needed outward calls from the NMS system to the caller. The formal structure of the NMS algorithm logic can designate that the NMS nurse either act on these action points as soon as they are reached (as a true end-point) or act on them "at the end of the algorithm". In the event that the NMS nurse reaches the end of an algorithm and the algorithm logic has made more than one recommended action, the NMS nurse will carry out the recommended action of the highest priority. Also important in understanding the NMS algorithms is realizing the distinction made in the node text between a "provider examination" (requires in-person contact between patient and provider) and a "provider evaluation" (which could be confined to a telephone conversation between caregiver and provider). The Self Care Instructions For many patients, self care under the supervision of a caregiver will be the most appropriate care. The NMS Self Care Instructions guide the NMS nurse in providing for the caregiver an explanation of what is likely going on, things to do to lessen symptoms, call-back guidelines for the caregiver to use, and a mechanism to schedule NMS callbacks to the caregiver, if appropriate and desired by the caller. Use of the NMS System Software The Network Management System software is started by selecting the Nursetool choice from the Motif Root Menu. An example of a Motif Root Menu is shown in FIG. 5. Use the mouse to position the pointer in an open area of the screen. Hold the left mouse button down. The Motif Root Menu displays. Drag down the menu to the Nursetool selection. Release the mouse button. The NMS Main button bar displays (see FIG. 6). Stopping the IAS Network Management System The NMS software is stopped by selecting the Close choice from the NMS Main button bar Window Manager Menu. Use the mouse to position the pointer on the Window Manager Menu button at the left edge of the title bar in the NMS Main button bar. (See FIG. 6.) Hold the left mouse button down. The Window Manager Menu displays. Drag down the menu to the Close selection. Release the mouse button. The NMS Main button bar and any open windows of the NMS software disappear from the computer screen. 1 Starting a Call Overview of the Call Process The NMS is intended to be used as the first point of contact for a patient entering the health care system--i.e., those seeking medical care, health care advice, or information. As such, it has been designed to support a range of health care needs including: Emergency calls Illness Care calls (symptomatic patients) Provider Selection calls Health care information calls Callbacks to the patient When a call is received or a patient transaction begins, a judgment must be made about the caller's needs. The initial version of the NMS currently provides for four types of calls: Emergency--Calls requiring immediate assessment of a patient's medical problem and possibly immediate referral of the patient to a provider for medical attention are handled through the Emergency process. Emergency calls do not require verification of the patient's eligibility for referral. Illness Care--Medical problems that are not emergencies, but require assessment of the patient's condition are processed as Illness Care calls. A series of algorithms are used to walk you through the assessment process. Illness Care calls require verification of the patient's eligibility record in the system. If eligibility records do not exist in the system, you may create a New Patient Chart to add the patient's eligibility record. Provider Selection--Calls requesting help in selecting physician the appropriate medical provider are processed as Provider Selection calls. The Provider Selection function can also be used when an Illness Care call results in requiring provider selection. Information--Patient requests for information on self-care and/or insurance rules for a particular plan are processed as Information calls. Information calls require verification of the patient's eligibility record in the system or creating a New Patient Chart. Other--Calls that are inappropriate for the NMS software are processed as Other calls. Processing a Call Click the Start Call button in the NMS Main button bar (FIG. 6) or press F1. The Caller Info window (FIG. 7) and the Call Type Selection bar (FIG. 8) display. The NMS Main button bar remains on the screen. Initial Information Initial information about the caller and the nature of the call is entered into the Caller Info window. The text box in the Caller Info window is a repository for free-form comments about the call. Comments entered here are saved as a permanent record with the other information entered during the call session. The Caller Info Window Click the Start Call button in the NMS Main button bar or press F1. Patient Problem/Nursing Assessment--Type the following: the caller's description of the patient's problem, and the nurse's assessment of the patient's problem. The description should be sufficiently detailed to assist in selecting an appropriate algorithm. You may add text to this box at any time during the call session. Additional comments will be saved to the database when the call session is ended. Caller Name--Type the first and last names of the caller (separated by a space), even if the caller is other than the patient. Relationship--Enter the caller's relationship to the patient. The list button opens a list box with the acceptable entries for this box. The choices are: Self Parent Grandparent Relative Friend Other Select (or type) Self if the caller is the patient Patient Name--Type the first, middle and last names of the patient (each separated by a space). If you entered Self in the Relationship text box, the Patient Name box will be automatically be filled in with the name you entered in the Caller Name text box. Phone Now--Type the phone number of the caller, even if the caller is other than the patient. Use the format: (401) 555-8571. OK--Click the OK button to save the information you entered in the Caller Info window. The Caller Info window remains open on the screen and the OK button dims. The Caller Info window will remain available on the screen as a window or an icon until the call session is ended. You may add data to the Patient Problem/Nursing Assessment text box or change the information in any of the other text boxes in the Caller Info window at any time during the call session. The additional information will be saved to the database when the call session is ended. Minimizing the Caller Info Window You may minimize the Caller Info window to an icon at any time during the call session. Click the close box in the top right corner of the window. The Caller Info window will be minimized to an icon at the bottom of the computer screen (FIG. 9). Opening the Caller Info Window Icon You may open the Caller Info window from its icon if desired. Double-click the Caller Info icon at the bottom of the computer screen. The Caller Info window will display What Next? When you have completed the required entries in the Caller Info window, select a call type from the Call Type Selection button bar as described above Selecting the Type of Call The Call Type Selection button bar is displayed when you select Start Call from the NMS Main button bar. Each button on the Call Type Selection button bar starts a different type of session for interacting with the caller. The Call Type Selection button bar remains displayed during a call session in case the nurse needs to change a call type. Emergency (F6) Click the Emergency button or press F6 when you perceive the caller has a life-threatening emergency that requires life support transportation (essentially equivalent to calling 911). This will start the Emergency call process so that you can direct the patient to immediate medical attention. Emergency calls do not require verification of the patient's eligibility for referral. Illness Care (F7) Medical problems that are not life-threatening emergencies, but require assessment of the patient's condition are processed as Illness Care calls. Illness Care calls make use of automated risk assessment algorithms to help the nurse assess the patient's level of risk. Illness Care calls require verification of the patient's eligibility record in the system. If eligibility records do not exist in the system, you may create a New Patient Chart to add the patient's eligibility record. Illness Care calls are described below. Provider Selection (F8) Patient requests for assistance in selecting a provider are processed as Provider Selection calls. Provider Selection calls begun by clicking the Provider Selection button in the Call Type Selection button bar or by pressing F8 require verification of the patient's eligibility record in the system or creation of a New Patient Chart However, when an Illness Care call session results in requiring assistance for provider selection, you can perform Provider Selection without passing through the Eligibility Verification window again. Provider Selection calls are described below. Information (F9) Patient requests for information on self-care and/or insurance rules for a particular plan are processed as Information calls. Information calls require verification of the patient's eligibility record in the system or creating a New Patient Chart. Information calls are described below. Other (F10) Calls that are inappropriate for the NMS Network Management System software are processed and recorded as Other calls. Other calls are described below. 2 Emergency Call Handling Select Emergency (F6) from the Call Type Selection button bar (FIG. 8) when the call presents a life-threatening emergency. The Emergency Handling Window Click the Emergency button in the Call Type Selection button bar (FIG. 8) or press F6. The Emergency Handling window (FIG. 10) displays. If the caller's name and telephone number are not already displayed in the Caller Name and Caller Phone boxes as a result of being entered in the Caller Info window, you should record the caller's name and telephone number in the Caller Name and Caller Phone boxes before or after activating emergency procedures. Caller Name--Type the first and last names of the caller (each separated by a space). Caller Phone--Enter the caller's telephone number. Use the format: (401) 555-8571. Assessment of Situation--Enter your assessment of the situation. You may enter this information before or after activating emergency procedures. OK--When you have activated emergency procedures (such as transferring the call to 911) and have completed entering the information in the Emergency Handling window, indicate completion of the Emergency call by clicking the OK button in Emergency Handling window. Cancel--If, during the call, you determine the situation is not an emergency, click the Cancel button in the Emergency Handling window. Then at the Call Type Selection button bar, select the appropriate call type to handle the call. 3 Finding, Creating and Viewing Patient Charts This section contains information on how to find a patient's chart when it already exists in the system, or create a new chart if none exists. The Eligibility Verification window has fields for entering specific information which will locate the chart of a patient who has used the system before. Eligibility Verification Your organization may require that you check the patient's eligibility to use the system. If so, Illness Care, Provider Selection, and Information calls require eligibility verification. After initiating one of these call types, the next step is to verify the patient's eligibility status by searching for the patient's records in the database using the Eligibility Verification window. The Eligibility Verification Window Click the Illness Care button (F7), the Provider Selection button (F8), or the Information button (F9) in the Call Type Selection button bar (FIG. 8). The Eligibility Verification window displays (see FIG. 11). If the patient's last name was entered in the Caller Info window (FIG. 7), the patient's last name displays in the Patient Last Name field of the Eligibility Verification window. Otherwise, initiate a search for the patient's records in the system, as follows. Enter a specific piece of information unique to the patient, such as the patient's social security number in the SSN field, or the Health Plan ID, to narrow the search quickly. Click the Check Eligibility button or press Esc+F11 to display in the Results box all eligible patients meeting the criteria you have entered so far. In the event the caller cannot give you the correct spelling of the patient's name or does not know the patient's SSN or Health Plan ID, try entering additional information in the remaining text boxes to identify the patient. If need be, you can click Check Eligibility or press Esc+F11 to display a list of all eligible patients in the Results box. When you find the patient listed in the Results box, click the patient's entry (if it is not already highlighted) and then click the OK button, or just double-click the entry, to close the Eligibility Verification window and view the patient's chart Patient Last Name--Type the patient's last name if it is not already displayed. Begin the name with a capital letter. If you are unsure of the spelling, use the wildcard search characters. Patient First Name--Type the patient's first name if it is not already displayed. Begin the name with a capital letter. Health Plan--Type the name of the patient's (or sponsor's) health insurance plan. Health Plan ID--Type the patient's identification number for the health insurance plan entered in the Health Plan box. This number will be the number on the patient's health insurance ID card. Social Security Number--Type the social security number of the patient's (or sponsor's social security number when appropriate). Use the format 123-45-6789. Sponsor's Employer--Type the name of the employer when the employer is a client of the system. Note: The entry in the Sponsor's Employer box is only helpful for checking eligibility. Patient Zip Code--Type the five-digit zip code for the patient's address. Use the format 12345. Note: If you type too many or too few digits, or letters rather than numbers, and then click Check Eligibility, the system displays an error message to that effect You will also get an error message if you type a zip code that the system doesn't recognize. In either case, click OK in the message box to return to the Eligibility Verification window. Patient Phone--Type the patient's telephone number, beginning with the area code. Use the format: (401) 555-8571. Check Eligibility--Click or press Esc+F11 when you have entered enough data in the text boxes to cause a reasonable search of the database for the patient. The list of names matching the search criteria will display in the Results box. You do not have to fill in each box to initiate a search. Results--Displays the list of names matching the search criteria If no patients are listed in the Results box after you click the Check Eligibility button, a message stating that no patients meet the criteria displays. Click the OK button in the message box, then double-check the accuracy of the Social Security Number entry or other text box entries and try Check Eligibility again before creating a new chart. OK--When the correct patient is highlighted in the Results box, click the OK button (or double click the patient's name in the Results box instead of using the OK button). The Eligibility Verification window will close and both the Algorithm Selection and the Patient Chart windows will open. New Patient--This button allows you to create a new patient chart using the New Patient Data Entry window (see FIG. 12). For example, if the patient requesting services has not used the system before, and they are not in your installation's database, the patient will not display as a choice in the Results box. In these cases, you may create a new patient chart by clicking the New Patient button. See below for information on the New Patient Data Entry window. Always check the Social Security Number text box entry and try the Check Eligibility button again before creating a new chart. If the patient has used the system before, but a chart cannot be found during eligibility verification, a new patient chart may be created. This situation should almost never occur, and should be noted in the Problem Notebook. See the pertinent section below for information on using the Problem Notebook. Creating a New Patient Chart If the patient requesting services has not used the system before, a patient chart may not exist for the patient. Always check the Social Security Number text box entry in the Eligibility Verification window and try the Check Eligibility button again before creating a new chart. When the patient is not found in the database, create a new patient chart by clicking the New Patient button in the Eligibility Verification window. This will open the New Patient Data Entry window. Note: If the patient has used the system before, but a chart cannot be found during eligibility verification, a new patient chart may be created. This situation should almost never occur, and should be noted in the Problem Notebook. See the pertinent section below for information on using the Problem Notebook. Any information entered into the Eligibility Verification search fields during an attempt to find a patient's chart will be transferred to the New Patient Data Entry window. The New Patient Data Entry Window (FIG. 12) Click the New Patient button in the Eligibility Verification window. The New Patient Data Entry window displays. Fill in as many of the New Patient Data Entry window text boxes as you would like. Note: The Patient's SSN and the Client boxes must be filled in. If you do not have the patient's social security number, enter a "0" (zero). If you do not have the information for the Client text box, use the default value. If you do not have some of the other information, leave the text box blank. Press Tab to advance to the next text box, or click on the text box you want to activate. Press Shift+Tab to return to the previous text box. Last Name--Type the patient's last name. Begin the name with a capital letter. First Name--Type the patient's first name. Begin the name with a capital letter. M--Type the patient's middle name or initial. Begin the name with a capital letter. Street Address--Type the patient's street address. City, State--The city and state are filled-in automatically after you enter the zip code. Zip Code--Type the patient's 5-digit zip code. Use the format 12345. Note: If you type too many or too few digits, or letters rather than numbers, and then click Check Eligibility, the system displays an error message to that effect You will also get an error message if you type a zip code that the system doesn't recognize. In either case, click OK in the message box to return to the New Patient Data Entry window to make a correction. Phone--Type the patient's telephone number, beginning with the area code. Use the format: (401) 555-8571. Date of Birth--Type the patient's date of birth in the format: 15-mar-94 (the month in all lower case letters). Gender--Click the list button, then click the appropriate choice in the list. Ethnic Origin--Click the list button, then click the appropriate choice in the list. Marital Status--Click the list button, then click the appropriate choice in the list. Patient's SSN--The patient's social security number must be entered. If the social security number is not known, type "0" (zero). Use the format: 555-14-2857. Sponsor's Employer--Type the name of the policy-holder's employer. Client--The name of the client must be entered. If the correct client for your installation is already displayed, you may just press the Tab key to advance to the next text box. Otherwise, click the list button, then click the appropriate client in the list. Plan Name--Click the list button and select a plan from the predefined list, or type the name of the plan if it does not appear on the list. Plan Type--Click the list button and select a plan type from the predefined list, or type the name of the plan type if it does not appear on the list. Health Plan ID--Type the patient's identification number for the health insurance plan. This number will be the number on the patient's health insurance ID card. Primary Physician--Type the name of the patient's primary physician. The primary physician you define here for the patient's chart will automatically be changed if an appointment is made with a different provider during a Provider Selection session begun for Administrative Reasons. This entry is also used in the Provider Selection function if the physician is defined as a provider in the database. OK--Click the OK button to record the new patient chart and leave the New Patient Data Entry window. The New Patient Data Entry window disappears and the Patient Chart window displays with the newly created patient information. Note: If a message stating the social security number you entered in the Patient's SSN text box already exists in a patient chart: Click the OK button in the message window. Click the Cancel button in the New Patient Data Entry window. Type the correct social security number in the Social Security Number text box in the Eligibility Verification window. Click the Check Eligibility button in the Eligibility Verification window. Click the OK button in the Eligibility Verification window to bring up the patient's chart. You may now proceed with the rest of-the call session (Illness Care or Information). See the section Viewing Patient Charts for information on the Patient Chart window. Cancel--Click the Cancel button to stop creating a new patient chart and return to the Eligibility Verification window. Any information you entered into the New Patient Data Entry window is lost when you click the Cancel button. Viewing Patient Charts The Patient Chart window (see FIG. 13) is for viewing information on file for the patient. You can use the buttons in this window to toggle between the various types of chart information available. Note: You cannot update the patient's chart from the Patient Chart window. Only the Nurse Administrator can update a patient's chart. If you need to update information in the patient's chart, make a note in the Problem Notebook containing the new information. See the pertinent section below for information on using the Problem Notebook. The Patient Chart Window (FIG. 13) Click on a patient's name in the Results box of the Eligibility Verification window and then click OK; or, Double-click on a patient's name in the Results box of the Eligibility Verification window. Click the OK button after completing a new patient chart. Once a patient's name is selected from the Eligibility Verification window, or a new patient chart is created, the Patient Chart window displays the identifying information available for the patient in the scrolling text box of the Patient Chart window. Identifying Information--The identifying information for the patient displays in the Patient Chart window when the Patient Chart window first opens (as shown in FIG. 13). After another type of information has been displayed by clicking one of the other buttons in the Patient Chart window, you can return to the identifying information display by clicking the Identifying Information button in the Patient Chart window. Health Information--Clicking the Health Information button in the Patient Chart window displays the information shown in FIG. 14. Demographic Information--Clicking the Demographic Information button in the Patient Chart window displays the information shown in FIG. 15. Prior NMS Contacts--Clicking the Prior NMS Contacts button in the Patient Chart window displays the information shown in FIG. 16. The most recent call record is displayed first To review older call records, use the scroll bar to page down in the display. Minimizing the Patient Chart Window You may minimize the Patient Chart window to an icon if desired. Click the close box in the top-right corner of the window. The Patient Chart window will be minimized to an icon at the bottom of the computer screen (FIG. 17). Opening the Patient Chart Window Icon You may open the Patient Chart window from its icon if desired. Double-click the Patient Chart icon at the bottom of the computer screen. The Patient Chart window displays. 4 Illness Care At the heart of the NMS Network Management System is a set of decision trees, or algorithms, enabling you to sort patients into different risk categories without requiring a medical diagnosis. With these algorithms, you can query the caller for answers to specific questions related to the patient's presenting symptoms. The algorithms branch to predefined actions based on the answers received, so that patients can be guided to an appropriate level and type of care for their problems based on their level of risk and potential needs. The NMS clinical algorithms are not intended to develop medical diagnoses; they do establish temporal urgency requirements and recommend level of intervention required for evaluating a caller's problem. While the Illness Care call process is relatively structured, it is designed for use by registered nurses who can override the recommendations of the system based on their professional nursing judgment. After you receive a call, select Illness Care from the Call Type Selection button bar (FIG. 8), and find or create the patient's chart, the system will bring you to the Algorithm Selection window (FIG. 18). The Algorithm Selection Window Click the OK button in the Eligibility Verification or in the New Patient Data Entry window. The Algorithm Selection window displays (see FIG. 18). The Algorithm Selection window offers alternative methods for finding the best algorithm to use when you are interviewing the patient. The alternatives are described below. Topical Listing--Eleven buttons are available for choosing a category of algorithms. Click the Topical Listing button for the medical category that best describes the patient's symptoms. When you have selected a medical category, a list of the algorithms within that category displays in the Alphabetical Listing box. Alphabetical Listing--Initially, this box displays an alphabetical list of all algorithms in the system. When you click on a medical category (one of the Topical Listing buttons), or enter keywords into the Keywords box, the list in the Alphabetical Listing box is narrowed to the algorithm(s) corresponding to the medical category you clicked and the keywords you entered. Keywords--The Keywords text box allows you to find an algorithm by typing in keywords that describe the patient's symptom(s). Each keyword--including the last--must be followed by a semicolon (;). As soon as you type the semicolon, the related algorithms will be listed in the Alphabetical Listing list box. An example of the list associated with the keyword "pain;" is shown in FIG. 19. Multi-word keywords must be connected by a hyphen (-). Abbreviations may be used. Note: If you clear the Keywords text box with the Backspace key, the full list of algorithms displays in the Alphabetical Listing box. Associated Algorithms--After clicking on an algorithm in the Alphabetical Listing box, this scrolling list box displays the names of the algorithms, together with their purposes, that are similar to the algorithm you chose, as a way to double-check that you are selecting the most appropriate algorithm. If an associated algorithm describes the patient's symptoms better than the algorithm in the Selected Algorithm box, click on the more appropriate algorithm name in the Associated Algorithms box. The name you select displays in the Selected Algorithm box. The purpose of the algorithm you selected displays in the Purpose of Selected Algorithm box. Selected Algorithm--When you click on an algorithm in the Associated Algorithms box, the name of the algorithm displays here. See FIG. 20. Purpose of Selected Algorithm--When the name of an algorithm displays in the Selected Algorithm box, the purpose of that algorithm displays in this box. Select--When you are satisfied that the item displayed in the Selected Algorithm box most closely corresponds to the patient's problem, click the Select button to advance to the Algorithm Summary window (FIG. 21) as follows. Click the Select button to advance to the Algorithm Summary window; or Double-click on an item in the Alphabetical Listing box to advance to the Algorithm Summary window. The Algorithm Summary Window The Algorithm Summary window contains a detailed overview of the selected algorithm inside a display-only scrolling text box. Click the Select button in the Algorithm Selection window; or Double-click on an item in the Alphabetical Listing box of the Algorithm Selection window FIG. 18). OK--Once you have reviewed the summary, click the OK button to close the Algorithm Summary window and to proceed with the first question of the algorithm If no algorithm summary exists, a message window displays in place of the Algorithm Summary window. Click the OK button in the message window to proceed with the first question of the algorithm. Algorithm Navigation Algorithm navigation takes place in the Algorithm Navigation window (FIG. 22). The Algorithm Navigation window presents clinical questions together with supporting lay questions. The answers to the clinical questions move you through the algorithm until you reach a list of actions. The algorithm navigation process requires you to record the caller's answers to the questions presented in the Algorithm Navigation window. As soon as you select the button that represents the caller's answer to the question, the system will present another series of questions or advance to the Nurse Action List window. The Algorithm Navigation Window Algorithm Name--This box displays the name of the algorithm from which questions are currently being asked. If a transfer to another algorithm takes place (e.g., a patient complaining of back pain also has chest pain and the system transfers to the Chest Pain algorithm), the name of the new algorithm displays. Clinical Question--Describes the current question in clinical terminology. Clinical questions are always yes/no questions. Lay Question--Provides suggestions for how the clinical question can be asked in language more appropriate for most callers. The lay questions may not necessarily be yes/no questions, but are intended to solicit the information the nurse needs to answer the clinical question. Rationale--Describes the reasoning for asking the current question, and may present an explanation if the patient answers yes to the current question. Yes--Click the Yes button or press Control+Y when the caller answers "yes" to the question. No--Click the No button or press Control+N when the caller answers "no" to the question. Unsure--When the caller cannot give a definite answer to the question, click the Unsure button or press Control+U to see a further discussion about the question. The Further Explanation window displays (see FIG. 23). Navigation window Click the OK button in the Further Explanation window to close it and proceed with the algorithm navigation process. Back--Click the Back button or press Control+B to back up and erase the previous answer and continue from the previous question. Comments--This space is provided to record any comments you may wish to make about the patient or the response to the question. Text entered into the Comments box is only saved with this question in the call record when you click the Insert button. Insert--Click the Insert button to save a comment you entered into the Comments text box. Once you insert a comment, it becomes a permanent part of the record of the current call and the comment cannot be deleted. Erase--Click the Erase button to remove a comment from the Comments box before clicking the Insert button. Once inserted, comments cannot be deleted. Nurse Action List Algorithm navigation for the call is completed when the Nurse Action List window (FIG. 24) displays. The Nurse Action List window presents a list of recommended actions to address the patient's condition. Depending on the action that you select, a different window will display. Possible Recommended Actions The possible actions are listed below in order of their medical priority: Activate Emergency Procedures--For potentially life-threatening emergencies requiring on-site or en-route care. Speak to IAS Provider--For possible need for EMS dispatch. A physician interview may identify a more appropriate action. Urgent Care--For care needed now, but EMS care on-site or en-route is not needed. Care could be delivered in the emergency room, clinic, or doctors' offices. Transfer to Algorithm--For transferring to the Algorithm Navigation window to navigate through a different algorithm. Speak To Provider--Sorting--For possible need for a provider visit. A physician interview may identify whether action is needed now (ASAP) or later (can be delayed for up to four hours). Speak To Provider--Treatment--For a physician interview to identify whether appropriate care can be initiated by phone. Early Illness Appointment--For an appointment with an appropriate provider "the next time the office is open." Routine Illness Appointment--For scheduling an appointment within two weeks. Self-Care--For problems which can safely be treated at home. The Nurse Action List Window The Nurse Action List window displays automatically after completion of the Algorithm Navigation. The top scrolling text box in the Nurse Action List window displays a list of recommended actions, prioritized by the system according to the order above. Usually, you will select the top-most action in the list. You may override the most highly recommended action and select another action that, in your judgement, is appropriate to address the patient's condition. Reasons for such overrides should be noted in the comments section of the Call Termination window. Highlight an action by clicking on it. Information displays in the boxes described below. The contents of these boxes change depending on which action is selected. Click the Select button. Select--When the action you want is highlighted (click on the action to highlight it), click the Select button to display the action's endpoint window. Clinical Rationale--An explanation of why the highlighted action is recommended. Message to Patient--Suggested language to use to explain the recommendation to the patient. Symptom Pattern--What the patient said to cause the system to generate this recommendation. Need to Consider--A clinical description of what conditions cannot safely be ruled out. When appropriate, this information will be passed on to the doctor. Provider Codes--This box contains the criteria for selecting an appropriate provider when you perform Provider Selection. Done--After you are done with Illness Care, click Done to exit algorithm navigation. A message will display asking if you are sure you want to end the medical assessment procedure. If you click Yes in the message window, both the Algorithm Navigation window and the Nurse Action List window close. If you click No in the message window, the Nurse Action List will remain displayed. Cancel--Click Cancel to return to the Algorithm Navigation window (FIG. 22). The effects of selecting one of the possible endpoints presented in the Nurse Action List window are shown in FIG. 25. Patient Self Care When you select ACCESS SELF CARE INSTRUCTIONS from the Nurse Action List, the system presents instructions for self care in the Self Care End Point window (FIG. 26). The Self Care End Point Window Instructions--The Instructions scrolling text box contains information organized into four categories: General Information and Education Instructions for Pain/Symptom Relief Watch Out For/Call Us Back For Callback Instructions Use this information to instruct the caller in understanding, accepting and carrying out self care. Does the Patient Accept--Click the appropriate radio button. If the patient does not accept the recommended action, clicking the No radio button and then clicking the OK button will close the Self Care End Point window and reopen the Nurse Action List window, where you may select a different action. Callback Date--If you determine a callback to the patient is appropriate, type the scheduled callback date using the format: 01-apr-94. This information will be presented in the Worklist window. Note: The month must be the first three letters of the month in all lowercase letters. Callback Time--Type the scheduled callback time using the format: 14:00 (the system uses a 24-hour clock). End Point Disposition--Click in the text box and type comments or concerns from the patient regarding self care, if any, or any comments pertinent to the callback because this information will be displayed in the Worklist window at the time of the callback. OK--Click the OK button to close the Self Care End Point window. Note: If you haven't filled in the Caller Name and Phone boxes in the Caller Info window, an error message will be presented telling you to do so. Cancel--Click the Cancel button at the bottom right corner of the window to close the Self Care End Point window, return to the Nurse Action List window, and select a different action. Other End Points This section describes more end points available as actions in the Nurse Action List window. Early Illness Appointment Assist the caller in establishing an appointment with an appropriate provider. Most often this will be an appointment within 48 hours. However, a call late Friday evening, for example, might result in an appointment Monday morning. If you select the Early Illness Appointment end point and the Provider Selection function is available on your system, the Do you want to perform Provider Selection? message window displays. Routine Illness Appointment Assist the caller in establishing a routine appointment with an appropriate provider. The appointment should be no later than two weeks from the date of the call. If you select the Routine Illness Appointment end point and the Provider Selection function is available on your system, the Do you want to perform Provider Selection? message window displays. Urgent Care Use when the patient needs care now, but does not need EMS care on-site or en-route. If you select the Urgent Care end point and the Provider Selection function is available on your system, the Do you want to perform Provider Selection? message window displays. Activate Emergency Procedures When you select ACTIVATE EMERGENCY PROCEDURES from the Nurse Action List, the Emergency Handling window displays. (See Section 2: Emergency Call Handling above). Follow the emergency procedures established at your installation. Use this action when there is a reason to suppose the need for on-site and en-route care beyond the capabilities of the typical caregiver. Transfer to Algorithm When you select TRANSFER TO ALGORITHM from the Nurse Action List, the Algorithm Navigation window (FIG. 22) for the new algorithm opens. (See Algorithm Navigation above.) Speak To NMS Provider Connect the caller to a supervising physician who will complete the triage encounter. Use this action when a possible need for emergency medical services exists, but a physician interview may identify more appropriate actions. When SPEAK TO NMS PROVIDER is the recommended action and you click the Select button in the Nurse Action List window, the Speak With NMS Provider window (FIG. 27) displays: Provider Name--Type the name of the doctor the caller will speak to, or select a name using the list button to display a list of provider names. Provider Comments--Type any comments the made by the doctor. Recommendation--Use the list button to enter the doctor's recommendation. Depending on the recommendation, the call may continue with Provider Selection if the Provider Selection function is available on your system. Does the Patient Accept?--Click the appropriate radio button indicating whether the patient accepts the doctors recommendation. OK--Click the OK button to conclude the illness care process. If the No radio button is selected, clicking the OK button will return you to the Nurse Action List where you may select a different action. Cancel--Click the Cancel button to return to the Nurse Action List and select another action. Speak To Provider--Treatment Assist the caller in speaking with a doctor who will decide whether appropriate care can be initiated by telephone with follow-up care by appointment. This doctor can be the patient's primary care physician, the physician covering for the patient's primary care physician, or a doctor in the employ of the patient's insurance carrier. Clicking the OK button opens the Speak With Provider window. When SPEAK TO PROVIDER is the recommended action and you click the OK button in the Nurse Action List window (FIG. 24), the Speak With Provider window (FIG. 28) displays: Provider Name--Type the name of the provider the patient will consult Does the Patient Accept?--Click the appropriate radio button indicating whether the patient accepts the doctor's recommendation. OK--Click the OK button to conclude the illness care process. If the No radio button is selected, clicking the OK button will return you to the Nurse Action List where you may select a different action. Cancel--Click the Cancel button to return to the Nurse Action List and select another action. Speak To Provider--Sorting-Now/Later Assist the caller in speaking with a doctor who will determine the appropriate next step in the patient's care. This doctor can be the patient's primary care physician, the physician covering for the patient's primary care physician, or a doctor in the employ of the patient's insurance carrier. The algorithm designates that this contact occur either "now" or "later". The "now" designation means that the caller should speak to the doctor as soon as possible. The "later" designation means that the contact can be delayed for up to four hours. Clicking the OK button opens the Speak With Provider window (see FIG. 28) described above. 5 Handling Requests for Information Callers may request information on self care and/or rules for a particular health plan. This will be an Information call type. Information calls require eligibility verification prior to access to medical or health plan information. Information Calls Use the Information button in the Call Type Selection button bar (FIG. 8) to handle Information calls, but do not use the Information button in the Call Type Selection button bar to access medical information if you are already processing a call, such as an Illness Care call. Doing so will log the call as an Information call instead of an Illness Care call. If you want to access information without changing the call type and without checking eligibility, use the Medical Information button in the NMS Main button bar (FIG. 6). Click the Information button in the Call Type Selection button bar or press F9. The Eligibility Verification window (FIG. 11) displays. The steps for using the Eligibility Verification window to locate a patient's chart are described in Section 3, Finding, Creating and Viewing Patient Charts. After the patient chart is found or created, the Information Type Selection window (FIG. 29) displays. The Information Type Selection Window The system groups requests for information into two categories: Medical Information Health Plan Rules You must select one of these categories from the Information Type Selection window. After clicking the Information button in the Call Type Selection button bar and selecting a patient in the Results box of the Eligibility Verification window, click the OK button in the Eligibility Verification window. The Information Type Selection window displays. The Information Type Selection window includes two radio buttons: Medical Information--Click the Medical Information radio button and then click the OK button to advance to the Self Care Selection window. Health Plan Rules--Click the Health Plan Rules radio button and then click the OK button to advance to the Health Plan Rules Selection window. OK--After selecting the radio button that corresponds to the requested information type, click the OK button to advance to the next window. Cancel--Click the Cancel button to stop the Information type of call. Clicking the Cancel button closes the Information Type Selection window. Medical Information When you choose Medical Information from the Information Type Selection window, the Self Care Selection window (FIG. 30) displays. The Self Care Selection window allows you to choose the particular self care information to retrieve. The Self Care Selection window, which is very similar to the Algorithm Selection window (FIG. 18), allows selection of a self-care instruction based on a medical category and provides a way to search for self care instruction using keywords. The Self Care Selection Window The Self Care Selection window displays when you click the Medical Information radio button and then click the OK button in the Information Type Selection window. Topical Listing--Click on the medical category that best describes the caller's request for information. A list of the corresponding self-care instructions displays in the Alphabetical Listing box. Alphabetical Listing--Initially, the Alphabetical Listing scrolling list box displays a list of all self-care instructions in the system. When you click on a medical category using one of the Topical Listing buttons, or enter keywords into the Keywords box, the list is narrowed to display the self care instructions that correspond to the medical category or keywords. You can double-click on an item in the Alphabetical Listing box to advance to the Self Care Instructions window (FIG. 31). Selected--This box displays the currently selected self care instruction item. Keywords--Find a self care instruction by typing keywords that describe patient's request for information. Each keyword--including the last--must be followed by a semicolon (;). Select--When you are satisfied that the item displayed in the Selected box corresponds to the patient's request for information, click the Select button to advance to the Self-Care Instructions window. Note: Double-clicking on an item in the Alphabetical Listing box has the same effect as clicking the Select button. The Self Care Instructions Window The Self Care Instructions window displays when you click the Select button or double-click on an item in the Alphabetical Listing box in the Self Care Selection window. Self Care Instructions--This is a display-only scrolling text box with the instructions corresponding to the self care item selected from the Self Care Selection window. OK--Click the OK button to exit the Self Care Instructions window when you are finished offering self care instruction to the caller. You may then either select another call type from the Call Type Selection Bar (see FIG. 8), or select Stop Call from the NMS Main button bar (see FIG. 6). Health Plan Rules When you choose Health Plan Rules from the Information Type Selection window, a Health Plan Rules Selection window (FIG. 32) displays. The Health Plan Rules Selection window contains three pull-down list boxes to select the information you wish to search for in order to answer the caller's request for information. The Health Plan Rules Selection Window The Health Plan Rules Selection window displays when you click the Health Plan Rules radio button and then click the OK button in the Information Type Selection window If the patient's chart does not contain information for the Client, Plan Name, and Plan Type boxes, these three boxes will be blank when the Health Plan Rules Selection window displays. To proceed, enter the information in the boxes, as described below. Client--The client currently associated with the patient is defined here. To add or change clients, click the list button to display a predefined list of clients. Scroll until the appropriate client name is highlighted and release the mouse button; or type the requested client into this box. Plan Name--The patient's current plan name is defined here. To add or change plan names, click the list button, then select the plan name from the predefined list, or type the requested plan name into this box. Plan Type--The patient's current plan type is defined here. To add or change the plan type, click the list button, then select the plan type from the predefined list, or type the requested plan type into this box. OK--Click the OK button to display the requested information in the Health Plan Rules window (FIG. 33). Cancel--Click the Cancel button to cancel a request for insurance rules information and close the Health Plan Rules Selection window. The Health Plan Rules Window The Health Plan Rules window displays when you click the OK button in the Health Plan Rules Selection window. Health Plan Rules--This is a display-only scrolling text box containing the requested health plan rules information. Note: If no health plan rules are available for the plan you selected in the Health Plan Rules Selection window, a message window may display. Click the OK button in the message window to continue. Click the OK button to close the Health Plan Rules window. 6 Other Calls In addition to the Emergency, Illness Care, Provider Selection and Information call types discussed in other sections, the NMS Network Management System provides for handling calls that are inappropriate for the NMS software. These calls are processed as Other calls. Click the Start Call button in the NMS Main button bar (FIG. 6) or press F1 to display the Call Type Selection button bar (FIG. 8). Handling Inappropriate Calls When you receive an invalid call (e.g., wrong number, prank call, etc.), select the Other (F10) button in the Call Type Selection button bar to display the OtherCall window (FIG. 34). The OtherCall Window Click the Other button in the Call Type Selection button bar or press F10. The OtherCall window displays. The OtherCall window contains a series of radio buttons to indicate types of inappropriate calls. Click the radio button that best describes the call: Wrong Number--Click this radio button if the caller simply dialed the wrong number. Phantom Call--Click this radio button if nobody is on the other end of the line. Prank Call--Click this radio button if the caller did not call for serious business, including obscene calls. Inappropriate Call--Click this radio button if the caller's request was inappropriate to the NMS Network Management System, but not described by the previous three options. OK--Click the OK button to record the information and leave the OtherCall window. Cancel--Click the Cancel button if you determine that the call is appropriate after all and you want to return to the Call Type Selection button bar to select a different call type. 7 Terminating a Call After the caller has been served, the NMS Network Management System provides a means to collect information about the utility and effectiveness of the system The Call Termination Window Click Stop Call in the NMS Main button bar or press F2 to open the Call Termination window (FIG. 35). The Call Termination window displays. Termination--Click the Normal radio button if the call session was successful. Click the Abnormal radio button if the call session was terminated before the normal processing was accomplished. What would patient have done if this service were not available?--Click the appropriate radio button. Sought emergency care--Click this radio button if you believe the patient would have sought Emergency Handling. Made appointment with physician--Click this radio button if you believe the patient would have set up an appointment to see a physician. Attempted self care--Click this radio button if you believe the patient would have tried Self Care. Other--Click this radio button when none of the other radio buttons in this set seems appropriate, and enter comments in the text box. The comments entered in this text box will be saved with the data for the call when you click the Done button. Tag for rapid retrieval?--Click the Yes or the No radio button, depending on whether the call session warrants further attention. Indicate Reason--Click the appropriate check boxes if you clicked the Yes radio button for Tag for rapid retrieval?. The call involved a potential lifesaving intervention The call involved a potential savings of medical costs The call was a noteworthy example of service value This was a problematic call--may require follow-up Comments--Enter any comments you have about the call session. Note: These comments will be displayed in the Patient Chart IAS Call Summary Report. Done--Click the Done button when you have finished with the Call Termination window. The Call Termination window will close and the call session will end. 8 Problem Notebook The Problem Notebook is a repository for problems you may encounter using the NMS Network Management System, or problems with the medical assessment process. In addition, you should use the Problem Notebook to record instances when the patient has used the system before, but a patient chart cannot be found during eligibility verification, or when a patient chart is inaccurate. The Problem Notebook can be used at any time before, during or after the call process. The Problem Notebook Window Click the Problem Notebook button in the NMS Main button bar (FIG. 6) or press F4. The Problem Notebook window (FIG. 36) displays. Entering Problems into the Problem Notebook Any user may enter a problem in the Problem Notebook. Clear--Click the Clear button to clear any information displaying in the Problem Description box. Problem Type--Choose from Medical Problem or System Problem using the list button. A Medical Problem relates to the medical information available for the call; a System Problem relates to a problem with the NMS software. Priority--Choose from Enhancement, Minor, Medium, Major, or Fatal using the list button. A description of each Priority type is as follows:
______________________________________
Values in Priority text box
Items in Priority list box
______________________________________
Enhancement An increase or modification in the
system functionality.
Minor The system can still be used because
the functioning of the system is not
significantly impaired by the problem.
Medium A workaround is available for this
functional problem, but increased
effort is required by some or all users.
Major Basic functionality is seriously
affected by this problem and manual
intervention is required.
Fatal The entire system is affected, so a fix
is required immediately.
______________________________________
Problem Description--Click in the Problem Description box and type your description of the problem or enhancement. Be as specific as possible in your description of a problem, i.e., how it occurred. Insert--Click the Insert button at the bottom center of the window to insert the problem into the Problem Notebook. OK--Click the OK button to record the information you entered and return to the window that was displayed before you opened the Problem Notebook window. Cancel--Click the Cancel button to exit the Problem Notebook without recording any information. Reviewing a Problem in the Problem Notebook Any user may review a problem in the Problem Notebook. Select the appropriate search criteria to locate the problem you are interested in reviewing. Select By--When you wish to review a problem, use the Select By list button to find problems by: Today's Date User Status Problem Type Priority Select Key--After choosing a search category using the Select By list button, use the Select Key list button to choose the criteria for the search. The contents of the Select Key list box change depending on what is currently selected in the Select By box (see the following table).
______________________________________
Values in Select By text box
Items in Select Key list box
______________________________________
User Only the Nurse Administrator can
view all user's problem descriptions.
Today's date The current date
Status Open
Resolved
Problem Type System Problem
Medical Problem
Priority Enhancement, Minor, Medium
Major, Fatal
______________________________________
The problems that match the Select By and Select Key values will be listed in the top display-only scrolling list box. Problem List--This box contains a list of problems already entered into the system. Click on an item in the list to view its description in the Problem Description text box; its status in the Status box; information concerning its resolution, if resolved, in the Problem Resolution text box; and who resolved the problem in the Resolved By box. OK--Click the OK button to return to the window that was displayed before you entered the Problem Notebook. Cancel--Click the Cancel button to exit the Problem Notebook. Resolving a Problem in the Problem Notebook The Nurse Administrator can update the Problem Notebook when: A problem has been resolved. The Problem Type changes. The Priority of a problem changes. Select the appropriate search criteria. Select By--When you wish to review a problem, use the Select By list button to find problems by: Today's Date User Status Problem Type Priority Select Key--After choosing a search category using the Select By list button, use the Select Key list button to choose the criteria for the search. The contents of the Select Key list box change depending on what is currently selected in the Select By box (see the following table). The problems that match the Select By and Select Key values will be listed in the top display-only scrolling list box. Problem List--This box contains a list of problems already entered into the system Click on an item in the list to view its description in the Problem Description text box and its status in the Status box Click in the Problem Resolution box. Problem Resolution--Type the description of the resolution of the problem. Status--Choose Resolved from the Status list box. Resolved By--Select your user ID from the Resolved By list box. Update--Click the Update button to update the Problem Notebook. OK--Click the OK button to record the information you entered and return to the window that was displayed before you opened the Problem Notebook window. Cancel--Click the Cancel button to exit the Problem Notebook without recording any information. 9 The Worklist The Worklist manages scheduled callbacks. You will use the Worklist button in the NMS Main button bar (FIG. 6) in two ways: To open the Callback Scheduling window (FIG. 38) and schedule a callback for the Worklist. The Callback Scheduling window automatically opens when you click the Worklist button while you are processing an Emergency, Illness Care, Provider Selection, or Information call. To open the Worklist window (FIG. 37) and view scheduled callbacks or perform a callback by accessing the Perform Callback window (FIG. 39). Clicking the Worklist button when you are not in the middle of a call session opens the Worklist window. This function of the Worklist button is described below. Scheduling a Callback In addition to scheduling a callback from the Self Care window (FIG. 26), a callback can be scheduled from the Callback Scheduling window while you are processing any kind of call. The following information is required for scheduling a callback: name of the caller telephone number of the caller time and date for the callback eligibility verified or a new patient chart created When you complete the entries in the Callback Scheduling window, the | ||||||