The right answer: When patients are calling you

There was a time when dealing with an answering service was simple, if not always convenient. Doctors had to make sure that the operators knew where they were all the time, whether at the hospital or out to dinner. And they also needed to remember to call for messages frequently.

But a panoply of new technology has made physicians reachable in myriad ways. Doctors can choose from human operators, digital or alphanumeric pagers, cellular phones, systems that transmit messages to the Internet, freestanding answering machines, many varieties of voice mail, and countless combinations of all of these.

When it comes down to it, however, what matters isn't the particular mix of human and machine but the end result: Are patients happy with how their concerns are handled after office hours, and are doctors confident that messages are being relayed securely and efficiently?

It often takes experimentation for a doctor to find a comfortable combination of personal service and gadgetry. Here are some tips to help you navigate a course that works well for you:

Insist on both good price and good service

Doctors, especially those in small practices, used to face a basic choice between finding an inexpensive answering service and getting mediocre results, or paying a lot of money for top-notch service, says Gary Ferguson, PharmD, the CEO of Nashville-based NotifyMD, an answering service with eight call centers and 14,000 physician clients nationwide. But automation has made affordable, reliable service achievable, he says.

"Now they can get both, and they should get both," Dr. Ferguson says. "[Services] should be evaluated based on quality, price, technology, the people behind the product and customer service."

Using live operators doesn't mean a service has to be costly, if the firm has its technological ducks in a row and knows how to screen calls efficiently, he says. "Every doctor, whether you are a solo practitioner or a 58-physician cardiology group, should look to simple technology that can save them money but which doesn't displace live voice."

Because doctors' answering service bills usually depend at least in part on how many calls are handled per month, and the length of these calls, efforts to reduce the use of the answering service when it's not needed can pay off. So-called "automated attendants" can filter out inappropriate calls before they reach an operator. A taped message explains that the office is closed or that no one is available to come to the phone, outlines the hours the practice is open, and gives the patient the opportunity to bypass an operator and leave a nonurgent message for practice personnel to retrieve later.

Having every call answered immediately by a human being is an laudable ideal, but practices that choose this route need to remember that the meter is running.

Be easy on callers

Doctors need to balance the usefulness of mechanized phone attendants, which employ touch tones and "phone trees" to direct and deflect callers, with patients' desire to reach someone with a pulse. Especially when sick and frazzled, patients might find navigating a maze of choices on voice mail to be maddening, and experts say poorly designed automated features can even put doctors at risk legally.

"The bottom line is that many callers are frightened, and they need the reassurance of a human voice," says Linda Greenwald, a risk management consultant with Boston-based ProMutual Group, which has advised physicians on the liability pitfalls of answering services. "There is nothing that replaces that."

An unremittingly long, automated laundry list of options at the outset of a call is a sure way to infuriate callers, and some simply might hang up.

"You don't want to have a list of seven or eight things," Greenwald says. "People get extremely frustrated. They will go doctor shopping for someone who has the courtesy to put a human being on the phone. Others will just hang up and try to take care of the problem themselves."

Greenwald's advice: "Picture yourself as an elderly, frightened person. What are you going to hear? That can be an eye-opener." Practice consultants, in fact, recommend that doctors ask friends or colleagues to test the efficiency and friendliness of their answering service and voice mail messages by making "phantom" calls to listen to voice mail and reporting back on their impressions.

Demand consistently superior service for your patients

Never settle for an answering service that jeopardizes patient loyalty or even health by routinely making errors or acting indifferently to your expectations. This is especially true as regional and national call centers are emerging and competing for physicians' business, providing alternatives to the local answering service that previously might have been the only game in town.

Linda McCoin, manager of corporate and medical staff affairs at Internal Medicine Associates of Bloomington, Ind., recalls that until two years ago, the 38-physician, growing practice relied on an answering service that was making more and more mistakes, and doctors were complaining about the problems to staff.

"Physicians wouldn't get their pages, or they would page the wrong physicians, or they would not follow the rules on which doctors should get which calls," she says. "The bigger we got, the more confusing our account got."

When the practice's contract expired two years ago, doctors switched to another local answering service that had recently come on the scene. Its work is precise and reliable, she says, and doctors are getting the calls they should be getting.

If alternatives exist, there's no need for doctors to tolerate services that put patients on hold for unreasonably long periods, speak to callers without the utmost courtesy, or maintain a staff of operators who are underpaid, get little training and who have no loyalty to the company or clients because of high turnover, says Nancy Duncan, founder of Frontline, an answering service in Indianapolis that has 2,300 physicians as customers.

"You have to run it as a business, and not all answering services are run as businesses," she says. "Some were started as family businesses, with grandpa and a cord board."

Consider voice mail alone, but with caution

A minority of practices shun the use of answering service operators altogether and funnel all after-hours calls to a voice mail box or an answering machine. This is a frugal alternative, and could work out well for a small practice or for doctors who don't mind sorting through lots of messages themselves.

Eight years ago, Bob Shields, DO, a family physician in Plano, Texas, got so tired of his answering service's shortcomings that he introduced a basic voice mail system instead, and hasn't regretted it since.

"They never could get everything straight," Dr. Shields says of the answering service. "On occasion they would actually almost triage [callers] for me and say, 'Is this that important? Dr. Shields is sleeping.' They might not be completely friendly with them, and they might be a little surly or tell them to go to the ER -- things they had no business doing. I wanted every call to come to me."

After-hours callers to Dr. Shields get a recording and are told to leave a nonurgent message ("press 1") or an urgent message ("press 2"). Nonurgent messages are taped and the doctor picks them up the next morning; the latter triggers the voice mail system to automatically call his cell phone. He can tell from the phone number displayed that a message is waiting, and he says he almost always is able to call a patient back within a half hour.

Most patients don't mind encountering voice mail, and Dr. Shields says having his wife record the outgoing message has made the greeting seem "more personal" and friendlier.

Still, doctors who ask their patients to simply leave messages at the beep should consider that they run the risk of customer relations problems if patients do dislike dealing with a machine or a voice mail box. Ask patients how they feel about the way calls are answered. Further, check your managed care contracts to see if you are required to provide 24-hour telephone access to an actual person rather than voice mail.

Express how quickly calls need action

Doctors should outline explicitly to answering services what kinds of calls need action immediately, which calls can wait for the following day, or whether they want to call back all patients and decide for themselves what's sufficiently urgent. And answering services need to know just how fast they are expected to pass on a call.

Kenneth Turner, MD, an obstetrician in Las Vegas, has had the same service for more than 25 years and knows exactly why the relationship has worked. "I expect that they call me right away," he says. "The main thing is reliability in calling you right away, and if they don't get you right away to keep calling. And I also think it's important for them to keep records of the calls, because you try to protect yourself legally in everything you do."

Another plus: The service knows when not to call. "Every patient who calls thinks it's an emergency but if the answering service is really [competent], it knows how to diffuse the call." His service long ago learned not to wake him up at home at 3 a.m. when a patient calls for a refill on her birth control pills. "This is a 24-hour town," he laughs.

As long as he gets urgent calls quickly, Dr. Turner is satisfied with a rather basic level of technology: being called on his cell phone or at home. "There's all new stuff all the time," he says. "But at my age [79], I'm not a technological wizard."

Answer your own phone

Some doctors probably resist giving patients direct access to their cell phone numbers, fearing being barraged with inappropriate calls. But cutting out the middleman entirely is an option for physicians who find answering services too expensive or unreliable.

At Santa Ynez Valley Medical Associates in Solvang, Calif., the three internists on staff recently found their answering service was taking a half hour to call back doctors when it should have taken five minutes, says Amy Comer Daniel, office manager. The service was costing doctors $400 a month, but sometimes doctors either never got their pages or were paged at home, at night, for no apparent reason. Other times, late calls would wake up the doctors' families.

The practice decided to buy cell phones for the doctors and to give patients phone numbers to reach the doctors directly. Only the on-call doctor is required to carry the phone, which is taken from the office at night instead of a pager. The system works well, Daniel says. Patients aren't taking up any more of doctors' time than they were when they initially reached a service. There have been a couple of glitches -- there was the time a doctor dropped her phone into a toilet and it sustained water damage, and the time a doctor sat on his phone and broke the antennae. And some elderly patients have had trouble understanding the cell phone numbers, which are given out to patients on the office voice mail. But all in all, the doctors like their do-it-yourself project.

"There was kind of a learning curve," Daniel says. "It did take a little while, initially." But the price, she adds, is right: $60 per month for the whole practice.