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Health Emergency Assistance Line and Triage Hub (HEALTH) Model

Chapter 6. Design

Why a Contact Center?

Experience has demonstrated (Chapter 5) that there would be a very high demand for direct communication in a bioterrorist event. Health emergency events, including disease outbreaks and disasters with implications for public health, universally result in large numbers of people calling local and State health and safety agencies. While to date the primary communication means has been telephone, a wider variety of means is now possible. Thus, we will use the term "contact centers" instead of "call centers." Contact centers would offer expanded choices for users to access information and could include telephone, E-mail, Web sites, Web-chat, fax, and video (Appendix H gives examples).

Public health authorities risk losing control of the public's perception of the event if they do not provide good risk communication. While television and radio broadcasts will provide information that is adequate for most of the public, there will always be concerned citizens or "worried well" who, for whatever reasons, require additional personalized communication. In the past, authorities have set up impromptu call centers to deal with the demand for individual communications. These call centers have been set up in response to disease outbreaks to give the public treatment advice or prophylaxis recommendations. Usually these centers use existing personnel who are drawn away from their usual duties. The drawbacks to the impromptu creation of a contact center include high cost, poor planning, loose organization, lack of security, ad hoc training of staff, and low capacity for consistency of data sharing and data collection. Additionally, the reactive creation of a contact center prevents systematic performance evaluation because basic metrics and measurements of effectiveness are generally not available.

An existing contact center, utilizing the best practices for risk communication in an emergency, is clearly a superior application of resources. Poison centers and nurse advice lines are already a primary point of contact for acute exposures and medical triage. Poison centers, in particular, are well known to the public and are trusted sources for information. Thus, the DHMIC proposes that existing medical contact centers may be appropriate repositories for creating and maintaining readiness to provide one-on-one health and medical information in a health emergency.

Processes

Designing the model started with a definition of what processes suit the model's needs, identifying how the call center and State health department's infrastructures needed to be integrated, understanding the existing call centers' processes, and identifying commonalties between processes within the various DHMIC call centers. This can be best visualized through a tool that we used called input/output information mapping. Once the steps in the process were identified, levels of service that drive the Health Emergency Assistance Line and Triage Hub (HEALTH) contact processes were determined. Through the implementation of the Smallpox Vaccination Support Services program, an operational management structure to support the HEALTH contact process was developed and tested. Finally, we addressed the legal requirements for security and privacy that would be required in the HEALTH model.

Ensuring Consistency of the Message With Decision Triage Trees

The service user (usually the State health department) approves the content of each decision tree, which will depend on the weapons-of-mass-destruction (WMD) agent or other type of event being responded to. A sample decision triage tree is available in Appendix I and on the CDC Web site at http://www.bt.cdc.gov/agent/smallpox/vaccination/clineval. At each juncture in the routing, a decision tree is used to dictate the route to be taken. Some decision trees will be at the discretion of the caller through interactive voice response (IVR); other decision trees will be decided through an information specialist using a series of pre-determined questions.

This system offers the best guarantee that a consistent message and consistent response to each call is delivered. Use of decision trees also minimizes training times and can allow for the use of information specialists without specialized medical training or licensing.

Using decision triage trees that are embedded in the software being used by the answering information specialist provides another important function. Offering information on public health topics can come close to crossing a line into offering medical advice or diagnosing symptoms. These practices could be a liability risk for the call center. The decision triage tree should prevent such errors by providing an appropriate answer or referral when a caller asks for medical advice. In spite of their knowledge and expertise, even nurses on health advice lines usually use medical triage software for just these reasons.

Testing Different Operational Management Models

Stand-Alone Management Model

In implementing the Smallpox Vaccination Program Support Services telephone lines, a stand-alone management model was used; that is, a call center manager and dedicated smallpox support services staff were hired for the duration of that service. Because of the high cost of maintaining readiness under this model, we attempted to convert to an integrated management model after the initial few weeks of operations.

Integrated Response Management Model

For HEALTH to function well, an integrated approach was necessary. However, this meant that the same staff who managed the NurseLine, Drug Center, and Poison Center had to take on additional roles to implement Colorado Provider & Hospital Information Line (CO-PHIL) and Colorado Health Emergency Line for Public (CO-HELP). Currently, the NurseLine, Drug Center, and Poison Center have 3 different managers and different protocols, skills, and software. For our agency, an integrated management plan would require the unification of management, processes, employee training, and systems at the three call centers. For these reasons the integrated management plan did not work and a modified integrated response management model was proposed.

Modified Integrated Response Management Model

Following discussions with DHMIC call center managers, a modified integrated response model was decided on. The modified model integrated the management of HEALTH into the NurseLine, with access to personnel and systems resources in the other two call centers when surge capacity was required. The model functioned on a day-to-day basis, and this competency was tested when the West Nile virus hotline was provided through CO-HELP.

This approach provided:

A management structure than can be scaled up or down to deal with a small planned event or a large surge by accessing personnel from the other call centers.
Defined roles and responsibilities for CO-HELP, CO-PHIL, and other call center personnel.
Minimized cost (does not require standardization of the different management processes of the three call centers) by focusing the integration into one program, the NurseLine.

Ensuring Privacy and Security

Within the three call centers at DHMIC, legal requirements, confidentiality, and privacy are well established for traditional telephone communications. This is another advantage that a medical call center has over an impromptu set-up. Current confidentiality policies must be updated to incorporate references to each new media channel (Web-chat, fax, E-mail), before it is brought on line. The policy statements regarding each media channel must specifically address users, authentication, confidentiality, security provisions, and usage rules.

When discussing personal or medical information in the delivery of service, a "notice and consent" form must be developed for patients who wish to use various media channels to communicate with the center. The notice advises contacts of the confidentiality and security issues, and identifies who will see their health information.

Directions must be provided on how to use the channels for communication or medical triage purposes. This includes information on how callers identify themselves, the specific kind of messages appropriate for E-mail, how to escalate issues when necessary, and cautions against using certain channels, E-mail for example, for emergencies or sensitive health issues.

Usage boundaries need to be defined. This includes how information is shared and forwarded and rules for handling.

Where the communication will be stored and whether it will be referenced to any personal identifiers must be determined.

Finally, technical security measures need to be developed to address HIPAA requirements, for example, the possible use of encryption technology and auditing mechanisms.

An example of a privacy policy statement that can be used follows.

The Center respects an individual's rights to privacy and strives to protect such rights when using E-mail to disseminate health-care information. It is important to note that E-mail communication is not entirely secure. All information collected by the Center, including your E-mail address, is confidential and is not shared with other organizations. Should information need to be disclosed to another organization, an informed consent will be obtained. Data collected augments your confidential medical record information and includes your E-mail address. At the present, E-mail is used solely for the purpose of disseminating health information to persons requesting such information. Should questions arise following receipt of the E-mail, the requestor needs to call the Center. Only authorized health providers, systems, and administrative staff of the Center have access to your information. The Center maintains a secure network, and measures are taken to ensure security.

The Center currently has a secure local area network (LAN) using network-based authentication of users and external access through a firewall. Users access the network through a log-in requiring an individual user name and password that expires every 60 days. Screen savers with password protection protect information on a computer workstation. As part of the new employee process, all personnel sign a security agreement. Network and desktop anti-virus software also protects data and systems. Training, policies, and procedures describe the security measures enforced, and job descriptions identify access rights to secured information.

To ensure data integrity, the Center will maintain and enforce a policy on record retention and retrieval and purging old documents. Data are currently backed up and stored on-site and off-site. In addition, disaster recovery processes include redundant telecommunications, computer systems, and T-1 connections and an emergency power supply to critical departments in the Center.

Measuring Performance

Measuring the performance of resources is key to providing quality management. Continuous quality improvement is an effective management tool to provide these measurements. This is actually part of the day-to-day operational management structure. It uses call metrics and other measures to assess the quality of the service provided and to identify and address inefficiencies in the processes. A continuous quality monitoring process that was used for the Smallpox Vaccination Program Support Service is available in Appendix J.

Continuous quality improvement steps:

Call audits:
1. Listening to calls or
2. Reviewing call data for:
Recording corrections or additions:
1. Written request is sent for record correction or additions.
2. Corrections are added to database.
3. Date and time of new entry are recorded.

Disaster Recovery Plan

DHMIC has plans in place for recovery from disasters. The types of events that must be planned for will vary for different agencies. We have planned for five types of events:

Mass toxic exposure resulting in a sudden and substantial increase in calls to the Poison Center.
Media crisis—any event involving a potentially toxic exposure requiring information dissemination to the media and public.
Paralytic disaster—any event that hinders or prevents DHMIC from providing services, such as natural or man-made events or extreme weather conditions resulting in mechanical breakdown of systems or preventing staff from reporting to work.
Fire at the DHMIC facility.
Tornado or severe weather warning for the DHMIC facility.

A generalized version of the DHMIC's Disaster Recovery Plan is included in Appendix K. Our plans address several components, outlined below, in preparing for a disaster. Activation of CO-HELP or CO-PHIL follows the same procedures, with the addition of the necessary request for service by the State health department.

Preparing for Systems and Facilities Failures

Preparing for a disaster requires installing redundant or back-up systems in case of power failure, communications system failure, or computer failure.
Planning for such systems failure may include planning for an alternative site; DHMIC has such plans in place through reciprocal agreements with two other western poison centers for calls to be routed to the alternative poison center in a paralytic disaster.
Alternatively, an agency may develop a facilities checklist to ensure that an alternative site chosen during an emergency will meet their needs.
For some agencies or types of events, new sets of equipment or facilities necessitate the preparation of emergency response kits, including 2-way radios, vital informational resources, and emergency call-down lists.

Assigning Roles and Responsibilities

Regardless of the severity of the emergency, roles and responsibilities must be defined in advance and incorporated into employees' training and performance objectives.

Decisionmaking should be consolidated. Experience has shown that decision-making by committee is dangerously inefficient during a disaster.
Chain of command must be pre-determined. For our agency, the type of event may indicate a different chain of command or response sequence; leadership during a loss of computers or telephone lines will primarily fall to the Director of Information Systems, whereas the response to a mass toxic exposure will be headed by the Director of the Poison Center.
Lines of communication must be pre-established. Call-down lists and contact information must be kept current, including contact information for partner agencies and media.
Responsibilities for all levels of staff must be pre-assigned and must be addressed in employee orientation, training, and evaluations.

People

We identified strategies to provide staffing capacity for emergencies and to define roles and responsibilities of volunteer and paid personnel during an event.

The strategies are:

Personnel profile.
Emergency/surge staffing.
Volunteer management plan.
Training plan.

Personnel Profile

The skill profile of the personnel needed is dependent on the level of service required; this would be determined by the nature of the event. With the administration of CO-HELP and CO-PHIL for the Smallpox Vaccination Program Support Service, two service level agreements (SLAs) were developed to meet the need of the Colorado Department of Public Health and Environment (CDPHE). Level One service requires information specialists who do not need to have a medical background. Level Two service requires access to licensed staff (nurses, pharmacists, and physicians). Job descriptions for both levels of service are included in Appendix L. Establishing these SLAs allowed us to quickly and easily clarify expectations with CDPHE. This will aid in quick start-up in the event of an emergency.

Level One Service

This basic service offers information by telephone and Internet, with recorded messages and information specialists available to answer questions via approved Frequently Asked Questions (FAQs), along with collection of the caller's county of origin and which FAQ was accessed.

Level Two Service

This expanded level of service would offer recorded information supplemented by available information specialists answering questions from approved FAQs and protocols, but would also offer decision support for the public from licensed professionals using pre-designed protocols or Centers for Disease Control and Prevention (CDC) clinical decision trees. This service would also offer decision support for symptoms reported by health care providers and symptom or exposure surveillance for the public health agency. The delivery method would include telephone, Web-based technology, information specialists, registered nurses, and pharmacists, with the possibility of consultations with other professionals (e.g., infectious disease specialists, epidemiologists, and toxicologists) as necessary.

Emergency/Surge Capacity Staffing

Based on research and the proposed multi-channel systems (described in Appendix P), it was determined that 59 people would be required to handle 1,000 contacts per hour if the various media channels (Internet, Web chat, E-mail and fax) were fully used. The staffing resource and contact surge calculators available in the tool set will calculate the number of people needed to handle emergencies of varying magnitude given whatever technology is available.

Internally, the DHMIC can draw on staff from the NurseLine, Drug Center, Poison Center, Research and Consulting Department, and Medical Toxicology. Use of in-house human resources for addressing surge capacity in a public health emergency requires development of an internal management plan for scheduling, payroll coding, and management as well as development of software and database linkages, cross-training, and maintaining existing services. It also requires maintaining a roster of staff who may have priority obligations elsewhere (such as National Guard or physicians who may be called to the Emergency Department). Declaration of an emergency would signal a move to the Incident Command System of management, allowing the call center Incident Commander to make decisions on surge capacity and emergency personnel resources.

Volunteer Management Plan

Externally, a pool of potential volunteers may need to be recruited and developed. From research on public health emergencies, volunteers, planned-for and unplanned-for, are a surprisingly consistent factor in disaster events. Volunteers are potentially a crucial resource that, if not planned for, can become an actual threat to security and site management. Volunteer management is required both to address unplanned-for volunteers showing up and to provide additional personnel to address surges in call volume. Nationally, health departments are developing lists of potential volunteers that can be called in large-scale emergencies. Medically licensed volunteers will be in demand. Planning for such an event requires the volunteer pool to be defined in advance. For DHMIC, recruitment and training of volunteers is a future task, and finalization of a volunteer management plan likewise will take time.

A volunteer management plan should include:

Pre-event recruitment.
Call-up procedures.
Training plan:
1. Advance training (pre-event training).
2. Emergency ("just in time") training.
Management plan:
1. Roles and responsibilities.
2. Incident command structure.
Security plan.
Evaluation:
1. Volunteer satisfaction.
2. Volunteer performance.

Training Plan

A training process was developed for and tested during the implementation of the Colorado Smallpox Vaccination Program Support Service and the West Nile virus hotline. Both projects had very rapid ramp-up times; implementation took less than one month. New personnel received 3 hours of didactic and 3 hours of practical training. Existing administrative personnel received training in the program in case of surges in call volume. A generalized training plan is available in Appendix F.

Technology

This component describes a conceptualization of the systems required to create the 21st-century contact center, which was visualized as the answer to the problem of emergency public health communications. A representation of the existing systems at DHMIC and the proposed augmentations is available in Appendix G. A technology expense calculator and a surge (technology) options matrix are included in the tool set.

The system allows the same call center staff person to manage multiple channels of contact, including voice, E-mail, Web chat, and fax, while accessing multiple databases for providing information, medical decision trees, or data collection. The concept provides information options to the public, is exportable, ensures the consistency of information, and is designed to handle surges of up to 1,000 callers per hour while getting priority calls through to skilled professionals. The complete description of the systems model on which this section is based is available in the component report entitled, HEALTH Multi-Channel Contact Center Specifications Concept Plan and Report (Appendix P), prepared for DHMIC by William Wood of Wood Associates Corporation, Highlands Ranch, CO.

In summary, the proposed systems provide:

IVR (interactive voice response):
1. Capable of automatic number identification (ANI) capture and computer telephony integration (CTI) (capture, store, write to other applications such as LVM e-Centaurus and CasePro).
2. Capable of interfacing with Web applications.
3. Capable of natural speech recognition.
Touchtone or "speak" input/prompt capture.
Multi-channel routing solution:
1. Capable of routing voice, E-mail, Web/chat, and fax work items.
Health care professional (contact center agent) desktop:
1. Ability to have a "screen-pop" of captured information from IVR or other routed channels in local databases/applications (LVM e-Centaurus and CasePro).
Health care professional (contact center agent) desktop REMOTE workstation.
Ability to work remotely with full function workstations.
Robust real-time and historical reporting system.

The Multi-Channel Contact Center

The general population will be able to access information from the World Wide Web or through a self-service application on an IVR or voice response unit (VRU) that will provide the latest information regarding the event. FAQs can be posted for use by the public either on the Web or through the IVR and updated as additional statistics and information are gathered from those reporting on the event.

We estimate conservatively that at least 40 percent of the general public could be satisfied through these two self-service sources of information. Although there was no tracking of self-service information sourcing in past public health events in our research, there is significant documentation regarding self-service channels in call centers. Depending on the industry (banking reporting the highest use of self-service channels), anywhere from 40 percent to 85 percent of traditional "voice channel" calls can be handled through self-service.* This estimate held up in our experience with the smallpox vaccination program, and with West Nile virus (WNV), when 54 percent and 45 percent of calls respectively were served by the recorded message alone. Health care providers could also use these self-service options, although we anticipate 50 percent reduction in usage from that of the general population. A small percentage of the symptomatic public (most likely self-determined as falling into that category) may be satisfied through these self-service options.

In Figure 2 we have plotted how 1,000 contacts per hour might be segmented by channel of choice for those clients requiring information regarding an event. There will still be a significant request volume via the traditional voice channel; however, with IVR augmenting that channel, it will help deflect part of the voice channel volume. The self-service options for both Web and IVR could reduce the need for agents by 53 percent, or 47 full-time equivalents (FTE), from 89 to 42 FTE.

National Performance Review, Federal Consortium. Putting Customers First; Serving the American Public: Best Practices in Telephone Service, 1997.

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