Proceedings of the 36th Hawaii International Conference on System Sciences - 2003

Establishing a Contact Centre for Public Health Care

Reima Suomia & Jarmo Thkpb Turku School of Economics and Business Administrationa,b Institute of Information Systems Science P.O. Box 110, FIN 20521 Turku, Finland Tel. +358-2-338 311, Fax +358-2-3383 451 reima.suomi@tukkk.fia, jarmo.tahkapaa@tukkk.fib Abstract
A growing part of population is used to performing transactions on-line via the Internet, even in relationships to authorities. Not even the health care sector can escape this trend. Patients put pressures on health care providers through contacting them through telephone and the Internet. In this article we discuss the future of contact centres in health care. We scan through the literature on the issue, present published projects and systems on the field, and build a conceptual model of the health care contact centre and its function. As a case example we follow the first steps of a contact centre to be implemented to the primary health care of the city of Turku. For this and clarity reasons, we restrict our discussion to the public health care, where customers can not be selected, and the operation is not run for profit, and to the mastering of acute diseases, where interaction with the customer needs to be fast and based on an individual transaction rather than a lasting patient-doctor relationship. Community Commerce Care Content refers to giving customers information about health and diseases. This kind of activity does not absolutely need human-human interaction, and as such is not at the center of our research. Healthoriented communities usually are communication platforms between users or customers, are set up spontaneously, and are not controlled by any specific organization [24]. As such, they do not fit to the kernel of our definition of a contact center. Commerce focuses on commercial transactions and at raising profit, and is not a key area for public health care. Our area of activity is that of care, where customer-spesific care and guidance is given. The communication flow just in a single patient consultation is a complicated one. Lagendijk et. al. [17] identify fourteen information flows in a model that they call The real life: 1. Patient input 2. Describe the diagnosis 3. Referral-letter 4. Examination request 5. Examination result 6. Input from external information 7. Referral from specialist to specialist 8. Non-medicamental homework for a patient 9. Medicamental prescription 10. Request for non-medicamental prescription 11. Request for clinical treatment 12. Feedback to general practitioner 13. Result from treatment 14. Feedback to patient. This model is already quite complicated, but most probably still incomplete. Suomi [31] has identified eight information system entities that are needed in a normal consultation, as in Figure 1. Already the integration of these systems is a magnificent task.

1.

Introduction

A growing part of population is used to performing transactions on-line via the Internet, even in relationships to authorities. Not even the health care sector can escape this trend. Patients put pressures on health care providers through contacting them through telephone and the Internet. In this article we discuss the future of contact centres in health care. Our research questions are What are the logical functions of a contact center in health care? What must be taken into action when building a health care contact center? How do contact centers improve the workflow of health care (health care chain)? Cain et.al. [4] define four Cs of electronic health care activity over the Internet: Content

0-7695-1874-5/03 $17.00 (C) 2003 IEEE

Proceedings of the 36th Hawaii International Conference on System Sciences - 2003

Decision support provision

Customer support tools

Interaction support tools

Consultation tools (front-end)

Preparation tools (back office)

Process support tools

Money related support tools

Management tools

Figure 1.

Classification of ICT tools in Health Care [31]

The promises of electronic communication in the health care industry include the following [21]: For both patients and physicians: ease of communication, avoidance of telephone tag, and reduction of medicontacty unnecessary visits For patients: improved access to care and advice For physicians: the opportunity for increased follow-up communication with patients and better patient satisfaction and retention. For the physician practice: the efficiency of fewer telephone contacts, more productive capability, and possible growth. Methodologically our research is mainly a conceptual one. However we include to our article a short analysis of the contact center solution in the city of Turku, Finland. We have not focused very strongly on the contact center in Turku before, but we have conducted intensive research on the total information technology solutions in Health Care in Turku, reported in several places and phases [32-34]. Our data gathering on the Turku solution is based on the data collected for this earlier research, plus on current interviews with the management of the Health Department in Turku.

2.

The concept of a contact center

Despite of the wide use of the word contact center, the concept is far from clear. We define here a contact center in health care as an organization-internal computer-telephone system supported by organizational arrangements to manage and integrate the conversation flow with health care customers aiming at perfect customer service and organizational efficiency in health-related issues, which integrate personal consultative visits and communication through electronic means, most

usually telephone and the Internet, at least partly substituting the former with the later In our concept, the contact center is operated by the health-care providing organization itself, not by any external agent or broker. This is not to say that some details of the operations could not be outsourced, such as running of the technical infrastructure. Further, in our definition the system must have facilities for integrating communication both on the telephone and data, mainly Internet-networks. Integration of different modes of communications has been identified as a key added value in earlier research too [5, 6, 30]. We want to stress that the system is not just a technical artefact: a well performing contact center must include organizational arrangements and definitions [3]. Establishing a contact centre in-house or outsourcing contact centre activities is a major organisational learning and change project [16]. The system is to increase customer service, at the same time making the use of organization-internal resources efficiently utilized. The concept of a contact center is less used than that of call center [16] [26]. Call centers utilize telephone technology, and maybe include computers support, but do not traditionally try to integrate customer contacts through other media. Call centers are often run by external expert organizations, and are a booming industry. In Europe about 75% of call centers revenue result from outsourcing. [15] By 2003 more than 30,000 contact centres are to be established in Europe and the total number of work opportunities in contact centres should have exceeded 1,450,000 by the end of 2001 [9]. The good news is that health-oriented contact centers can to a great extent use the same tools and concepts that call centers do. Within computer industry, the concept of help desk has won popularity [13, 27, 37]. It is clearly related to contact centers, but the difference is that help desks focus on immediate operational problems, and aim at instant solutions. In our terminology, they would be tools for transaction management. In the public sector communication centers have been used more or less as a help-desks or information points. In health care there are now however examples of effective communication centers like that of NHS-direct in Britain [15] and Telefonakuten in Stockholm province in Sweden. The concepts of communication centers and contact centers are both using several medias to communicate with the customers and can therefore be seen as similar activity. There is also a expression customer access centers in use which is also related to communication and contact centers to enable all customer interactions with the organisation. [1]

0-7695-1874-5/03 $17.00 (C) 2003 IEEE

Proceedings of the 36th Hawaii International Conference on System Sciences - 2003

3. Earlier literature and solutions on the area

Managing customer contacts has included the following phases of major media availability [1]: Face-to-face customer contacts Correspondence delivered by the Post Office The telephone with toll calls The telephone with toll-free calls Facsimile transmission of correspondence E-mail correspondence The Internet and the corporate Web sites This reflects also the path from call center to contact or communication center. Related to todays state of the art communication centers, the early models of call centers were characterized by low connectivity, interactivity and agility. The content of services was limited by three factors: first the connections were analog which before the fax limited the transaction to use just voicebased. Second, the scripts and manuals were hard copy and expensive to codify and slow to consult and thus the interactivity was low. Third, the agility was limited by workflow and staffing arrangements that were more rule- rather than role-based - the aim was to lower call center costs through hierarchic supervision. [15], [1] The last ten years have been a period of higher connectivity and interactivity though the agility is still often low. The increasing networked nature of ICT has enabled this development. Computer-telephony integration (CTI) has enabled call centers to become an important business instrument in expanding industries like travel, financial and insurance services, software and hardware, just to name a few. In this stage the connectivity is both analog and digital, supporting asynchronous voice, data and still picture transmission with callers. Interactivity is also better because of better integration of the CTI to databases, customer routing to appropriate agents becomes more a demand- rather than supply-led service. Agility is however still limited because CTIs over-lay existing structures and business processes rather than stimulate their re-engineering [15]. The development of technology has had the strong influence that call centers have moved from back office support to the front-line of the organisation. Call centers are equipped with latest technology in both voice and data applications and in addition the focus is moving from mostly telephone calls to all forms of customer access including e-mail, fax-mail, kiosk and Internet. The multimedia touchpoints are evolving rapidly, and therefore the call center is fast becoming as Anton expresses customer access centers [1] or contact centers. The key driver in this development is the growing awareness that managing customer relationships is raising the bottom-line profits [1].

Anton [1] has highlighted top strategic solutions which will change the customer access center in the future. Those are: Voice over Internet Protocol (VoIP) Interactive Voice Response (IVR) and voice recognition Database engines and knowledgeware E-mail management software Value-based caller routing Computer simulated training Computer-telephony integration Middleware. In the health care the development has been somewhat the same. The communication between patient and health care staff has taken place through face-to-face contacts and telephone. Further the contact is very often limited to certain time of the day. The contacts are centred to one telephone number where a customer can call to get medical advises. Very often the staff in this number also handles other functions in the department so the concentration to the service is probably not in the best level. So far the development of information systems in health care has been several years behind general development in most other industries. [23] This is the case also in the use of call and communication centers in the health care. However, along with the development in ICT also the health care environment has increased its use of technology first in clinical systems and later e.g. in patient administration systems. Examples of developed communication centers are e.g. NHS-direct in Britain, Telefonakuten in Sweden and MediNeuvo in Finland. All are established during the last few years. Next we will introduce these solutions shortly. Out of these three NHS Direct (http://www.nhsdirect.nhs.uk) is the oldest and largest both in activities and regionally. It was set up in 1998 and its telephone service handles 7.5 million calls a year. It is operating in England and in Wales and is going to be launched in Scotland in 2002. The services are available behind one telephone number 24-hour and are nurse-led providing healthcare advice and information. NHS Direct is not offering services only by telephone but also through wide area of different media. NHS Direct Online is a web site launched 1999 (relaunched 2001), where a customer can find health information in different form and for different purpose. Services include an online health encyclopedia, self-help guide, information about healthy living and local services. Health encyclopedia includes also information in multimedia and in audio clips. NHS Direct includes also digital television and touch screen machines in e.g. shopping centers, pharmacies, hospitals and libraries [20]. The services are offered by NHS and it produces mostly these services. It has outsourced some services but naturally monitors the contents very carefully.

0-7695-1874-5/03 $17.00 (C) 2003 IEEE

Proceedings of the 36th Hawaii International Conference on System Sciences - 2003

In the basic contact situation the caller is first asked some personal information by a call handler and after that he/she is connected to the nurse. Nurse will then decide whether the caller needs consultation time for a doctor or whether he/she manages with self-care. For the track-keeping all the calls are recorded, which is also mentioned to the caller. The online service is possible to use also via e-mail. However the respond time is relatively long, up to five days and the customer is asked to use telephone service if the case is acute. The results of NHS Direct are mixed. The demand for NHS services overall has not fallen but in the areas where services of NHS Direct, existing out of hours general practice cooperatives and ambulance services have been integrated, the demand for general practice consultation has fallen. There is a concern whether the service really reduces visits to doctor. The nurses advice may vary and is usually on the side of caution. Nurses have a decision support system in use, developed by NHS itself, but the predictive value of it is limited especially in the case of a serious or rare illness. If the illness is rare the system doesnt have enough information cumulated about it. Because the information is incomplete many other symptoms might fall in its category. The nurses err on the side of safety and will probably send the caller to a doctor. The unnecessary use of health care staff will not decrease in these cases. [12] The second example is the Swedish TelefonAkuten (http://www.telefonakuten.se), a service basically similar to NHS Direct, but which operates in a smaller scale. It provides advises in cases of both basic and special health care through telephone and the Internet. It was established in December 1999 and acts as a health care contact centre in the province of Stockholm and as service provider of occupational health for Stockholms public sector organisations. The service is provided by public health care but it is outsourced to a private company Telefonakuten Sverige AB which is a subsidiary of Medhelp AB. There are about 50 nurses working in Telefonakuten with 10-35 years of work experience from health care and a doctor who has the medical responsibility. The basic contact routing happens when a customer calls to TelefonAkutens number and the answering machine tells that he/she has called to TelefonAkutens service and that the call will be connected to a medical personnel. All calls are recorded but unlike in the NHS Direct this is not told to the customer. The calls are constantly analysed and developed by mystery calls in which e.g. a health care professional or a researcher calls to TelefonAkuten pretending a customer. The calls are analysed afterwards together with the management of TelefonAkuten and by the person who answered the call. A decisions support system (DSS) for the staff is in use to identify the illness faster. The user enters information about the callers illness and the system follows a trail according to features of the illness to offer a solution to the user. The trail is based on

cumulative information gathered to the system. There is a group of one doctor and four nurses who are developing the DSS system based on the information and experience gathered from use and latest medical research and development. To serve data provision and track keeping the trails are stored as a part of the callers cumulative patient record since the responsibility of medical services is high. The information gathered in the system are in use by the local public health centers where the staff can see the advice given by Telefonakuten but not vice versa. It is not possible to make appointments to a doctor or nurse but the caller gets information where to contact. The third example is the service called MediNeuvo (www.medineuvo.fi), which is the latest of these three examples, starting its activities in the spring 2002 in Finland. The service is in use in the area of Helsinki at the moment but aims at widening its activities nationwide. Its concept is based on the Swedish TelefonAkuten and it is also partly owned by MedHelp AB. The service concept is offered to public and private health care, but also to the insurance companies and other organisations providing health care and health related services. There are 30-40 health care professionals working in the contact center. The services offered, or at the moment are planned to be offered are health instructions, service instructions, logistics services (appointments, results of tests, preparation of tests, consultation and guidance of visits to a doctor). There are also services of added value under development like support and follow-up of self-care, safety services for elderly people and their relatives. The service is either totally or partly replacing the nation-wide medical advice number 10023 in the Helsinki area. The basic concept of all these three services is to offer medical advice and consultation from the same number. The aim is also not to act just as a call center but rather as a contact or communication center where customer can contact through different media and have interactive communication. The staffing principle in all the cases is similar there are nurses answering the calls and the doctors are used only in difficult cases. The contact-routing differs so that in the NHSDirect the caller is first discussing with the telephone exchange giving the personal details and some information about the illness and first after that she/he is connected to health care staff whereas in TelefonAkuten and MediNeuvo the call goes straight to the health care staff). Data about the caller is cumulated to the systems. Naturally, the patient records start cumulating only after first call. The problem is at least in Sweden and in Finland that the patient data in other health care organisations is not available in contact centers because of the tight patient information privacy protection the information can be transferred to another organisation only with the permission of the owner of the data who is the patient himself. This has been under close discussion already for some time in

0-7695-1874-5/03 $17.00 (C) 2003 IEEE

Proceedings of the 36th Hawaii International Conference on System Sciences - 2003

an attempt to establish a nation-wide personal medical database. Similarity in data provision in these three systems is the use of decision support systems to identify the illness. The system together with the recorded call and the information the nurse enters to the system during the call forms the patient record. This path should be possible to track afterwards e.g. in the case of a malpractice. Another essential reason for the records is that the development of the decision support system is based very much on the information collected from cases. And of course the identification of callers illness is also based on the earlier calls and patient record which have to be accessible easily and should be in a clear and unambiguous form.

4. A model for a contact centre in health care

In this section we build up a conceptual model of contact-center operations in health care. The model Figure 2.

should be a blueprint of the issues that must be taken into account when building contact center solutions for health care. Our model for contact centres in health care contains the domains of system and actor. Activities in the system domain are controlled by the system, activities in the actor domain by the actor. With this we want to emphasize that the communication act is anyway initiated and guided by the actors of the communication act, and cannot be totally controlled through even the most careful system design. The transaction between a customer and the contact centre happens in a socio-technical system, and the social side cannot be totally modelled and controlled. Here we need education and social innovation [2] at the side of technical design to make the system use a success. The heart of our model is in the added-value components the system can perform in the communication act.

A model for a contact centre in health care

Actor domain
Media selection database search

Situation Syncronization needs

on-line off-line

well-being newly diagnosted chronically ill

Media richness needs

text, structured spoken visual

e-mail phone edi-type on-line consultation

Contact initiator -Inbound -Outbound

Caller identification

Issue type identification -Operational -Clinical

Data provision

Track keeping

Contact routing

transaction management episode management harm life-cycle management person life-cycle management

System domain

Data base log file patient data

0-7695-1874-5/03 $17.00 (C) 2003 IEEE

Proceedings of the 36th Hawaii International Conference on System Sciences - 2003

The added values are: contacter identification contact routing, data provision track-keeping Contacter identification caters for the identification of the contact-taker. Key questions are: is he or she entitled to the service demanded, and is the person contacting really the one he/she claims to be [18]. Traditional methods for communication partner identification can be used here: user IDs and passwords, smart cards, or at the simplest form just asking for the social security number, that each person is expected to hold back just for him/herself. Contact routing is at the hearth of the system functionalities. Here the key is that the communication act is directed towards the right recipient, either human or system. Timely service is of key importance, also delays should be not too long. The main routing decisions are already made at the actor domain, but a lot still remains to do at the system domain. Say the patient insists on having a conversation with the doctor, there is little the system can any more do. However, for example options for answering to an e-mail are many more and worth considering. For the routing decision, the type of issue is of critical importance. For clinical issues, the contact must be taken care by a health care professional, whereas operational contacts can and must be handled by other staff. Examples of operational issues are concultancy time reservations and cancellations, issues having to do with payment, etc Data provision is needed in order to make the communication act fluent. The contact recipient must have up-to-date information about the contact-taker. Without proper basic data, wrong interpretations will step in [19]. Computer-telephony interaction [14] holds a strong promise here. Computer-telephony interaction refers to solutions, where customer data is automaticontacty fetched from data-bases based on the contacter identification, to be ready for use at the timepoint of interaction. Here data security concerns are of key importance: for example a dentist or office clerk should not be allowed to scan personal data on issues not at their area of expertise. Data provision can just be implemented through decent contacter identification. Finally, assisting in track keeping of the interactions is of crucial. What was the outcome of the contact? The contact protocol can just be recorded by the human recipient, but the system can help in the process. In the case of contacts to computer systems, they have the possibility to keep track of the interactions, just for example as in the case of Internet banking. Should any charges and financial settlements follow the communication act, these belong to this task of track keeping. Track-keeping has different time horisonts. We introduce here the terms transaction, episode, harm

life-cycle and person life-cycle. With a transaction we refer to a single communication act between a patient and a care-taking person: the list of Lagendijk & al above lists typical transactions. With an episode we refer to a set of transactions, after which the case are considered to be closed for the time being. A typical example would be an operation at a hospital: after sending the patient home this episode is over. With a harm life-cycle we refer to the total lifecycle of some harm: many diseases might continue over the whole life of the patient, some are however limited: for example operating and healing a broken leg is in most cases a time-limited activity. We might define that a single transaction necessitates tens of messages, an episode hundreds of them, and a harm lifecycle may consume from thousands to millions of messages. To give an example: a patient suffering from diabetes might have to make millions of transactions during his/her life because of the diseases. A person lifecycle contains his/her whole life, and contains of course a number of harm life-cycles. For data provision and track-keeping, an integrated data base is needed. It contains the customer/patient data, and a part of it log files of the customer transactions with the contact center. As said, a lot of ramifications of the contact are born in the actor domain. Here we discuss some of the main topics. First, from the health care provider point of view, the communication act can be outbound or inbound. We have discussed other topics with the inbound contacts in mind. However, health care providers too have to initiate contacts, and here the system must help in the contacting. Selection of media can and must vary a lot: consider for example reporting to relatives of a sudden death [35] or sending out a statistical survey, to take two extreme examples. The selected media can be any, but for the electronic communication we see the options of e-mail phone edi-type on-line consultation and database search. E-mail and phone are self-evident. With edi-type communication we refer to structured communication. For example, a patient control device might send some structured data to the health care institution, say blood pressure or body temperature data. By on-line consultation we refer to interactive discussion, that offers more than phone: usually the added element is vision, but it might too be for example on-line structured data. By database search we refer to a situation where the customer/patient is running selfservice through interactions with data bases. Typical search on the net for health-related information like in NHS Direct Online, or reserving a consultation time from a web-based system would be typical examples. Media selection has two main parameters. The first is whether the communication must be interactive, also on-line, or whether an off-line mode is enough.

0-7695-1874-5/03 $17.00 (C) 2003 IEEE

Proceedings of the 36th Hawaii International Conference on System Sciences - 2003

With on-line needs, just phone, on-line consultation, and in the case of self-service database search come into question. Communication around health issues is very sensitive. Media richness issues are critically important [7, 8, 10, 11, 25, 28, 29]. The very basic form of communication is that with structured data. Adding free textual symbols already makes the communication channel richer. Spoken information already adds personality and mood cues, and visual communication is considered to be the richest form of communication in electronic form, next to meeting personally. Spoken information needs not absolutely to be human-human interactive: consider for example telephone services and automated messages on the telephone systems. There is reason to differentiate between three groups of customers as it comes to health-care related information and communication needs: The well The newly diagnosed The chronicontacty ill and their care-takers. This kind of taxonomy is for example adopted in [4] and [36]. The well are untargeted and unpredictable in their communication patterns and needs. The chronicontacty ill have the most structured communication needs, and they are heavy users for health care services. For the newly diagnosted, speed of service is of greatest value. Just to give an example of the versatility and universal nature of our model, consider the case of automatic exchange of patient sensor data. Imagine a pulse monitor that would automatically send patient pulse data to a health care organization. In our model, we then speak of off-line, structured data exchange that takes place in an edi-type environment, though in most modern solutions most likely over a mobile phone network. The incoming data is automatically identified, and led to the patient data phase for later analysis. In the way there could be some preliminary automatic scanning of the data: if something alarming seems to be included into the data, the data could automatically be forwarded to a doctor. 5.

Case Study: Contact Centre in the primary health care of City of Turku

Turku is the fifth biggest city of Finland with some 170 000 inhabitants and lies in the south-west coast of Finland. During the years 1998 2002 there was a large information systems development project in the health care department of the city. A part of the development project is a development of service which is called a contact centre. Health care advising has been so far taken place in a call centre under one number 10023. The same number is used nation-wide. 10023 call centre in Turku area is giving only health advices and dont e.g. book appointments to a doctor. The service is run by nurses partly working at a same time also in other duties.

The contact centre project started at January 2002 as a six month pilot project in four units in Turkus health care. The purpose of the pilot was to find out how and what kind of contact centre concept could be used in the city. The service included health guidance, service guidance and booking appointments to a doctor or nurse. Approximately 12 nurses were working in the centre in shifts days and nights. However, compared to the examples above, this pilot could be seen as a simplified model there were no Internet, e-mails or online self -help sites in use, neither there was a decision support system in use. Next we will discuss our case example based on the earlier model of contact centre. The contact starts when the customer calls to a number which he/she has always used in contacting the health care. She/he assumes that the call goes to a health centre or unit which he/she meant to contact and the staff in the centre dont correct this assumption. The calls are not recorded but the nurse makes the necessary notes to the patient information record system during the call. This is fundamentally different from more developed services described earlier in this article. This prevents the information chain to become broken since the information which the nurse enters to the system is based on her/his subjective evaluation of the importance of the piece of information. This demands substantial professional skills. Contacter identification is taken care by asking the callers for their social security number. Since the contact is conducted by phone this is the only way to identify the caller. With the number the staff get access to the callers medical history. The key question here is that of information security. How does the staff know that the social security number is not in the wrong hands? The problem of course occurs also in using passwords or e.g. smart cards. The responsibility of keeping that information safe is for the owners. Contact routing is dependent of issue type. Most of the issues are clinical in nature. Because the service was insourced and the callers earlier health records were in use in a newly implemented electronic patient record system, the routing was easier than in the outsourced solutions earlier. Especially in the case of newly diagnosed or chronically ill the staff could instantly see with whom the caller has been in contact or e.g. what laboratory tests had been taken. Data provision and track keeping is easier in our case organisation than in earlier outsourced solutions since there is the integrated database in use which includes the patient health information. The earlier patient record is crucial in making decision and is in many ways even more important than using a DSS which gives only average advice based on earlier cases. The information in contact centre is mostly inbound, the customers also initiate the contact. The phone-based system would allow also outbound communication but in the contact centre the

0-7695-1874-5/03 $17.00 (C) 2003 IEEE

Proceedings of the 36th Hawaii International Conference on System Sciences - 2003

possibility is not in active use. Changes e.g. in bookings for doctor or informing the results of laboratory tests are examples which could be used in outbound communication. Media selection was limited by the service provider to a phone. The communication also happens on-line and in the sense of media richness supports the personality and mood cues of the communicators (patient and staff). Some severe problems emerged already in the beginning. Because extensive development of information systems has just been finished, the personnel was tired of changes and nobody wanted voluntarily to act as a pilot unit. Therefore two out of four units had to be ordered to take part in the project. This is one of the worst errors one can make in an IS project. Those two units withdrew after four months pilot section so the results were not encouraging. Other two are still continuing the pilot and after a five months trial seem to be satisfied with the concept. However those two units are not presenting a very extensive sample of health services. Another was the old 10023 service which acted very much in the same concept as previously and another was dentists. If we look at the Turku contact centre case through the theoretical model of Figure 2, we can see that the functionality of the system in Turku is quite limited. The system is just for inbound communication. The only media is phone, which leads to on-line spoken information exchange. No other means of communication are available. Customers can be as well well-being, newly diagnosed or chronically ill. The person contacted has access to a patient database, but there is no automation in providing that data. Neither are there any means to help in contact routing, also operational and clinical issues are discussed in the same contact. As there is no computer-telephony integration provided, the system does not help in the track-keeping of the patients calls and communication. Though the case illustrates more or less how a contact centre should not be established, the content of it has also advantages as compared to the examples from literature. The availability of the callers earlier medical records can be a crucial information in making decision. In an outsourced implementation it is not possible. However the case addresses that some kind of half- or trial-implementation dont probably give the desired results. The concept requires total implementation of a centre in certain area so that the information gathered from both the traditional doctors reception and from the contact centre is in use for the whole organisation. The use of one contact solution in all departments or units would also be a more straightforward solution for the customers.

6. Conclusions
In our article we have defined a conceptual model of a contact center for health care. A contact center should be versatile in functions, and offer support for

communication situations taking place in different contexts and medias. As key functions for a contact center in health care we define: Caller identification Contact routing Data provision Track keeping All these functions need sophisticated computertelephony-integration solutions, which are hard to establish as off-the-self solutions are not yet there. Our model emphasises the different activity spans in the patient-health care professional contact. We defined the interactions of transaction, episode, harm life-cycle and person life-cycle, from the shortest to the longest one. Our model also stresses the fact that no matter how a sophisticated system there might be, the communication situation is anyway framed by the actions of the active communication iniator, usually the patient. His or her behaviour is usually unpredicted, and it cannot be modelled. Especially this comes out in critical and sensitive situations, as health care situations often tend to be. If the patient selects a less than optimal communication media, one has to live with that, and still capture the needed data to the computerized system. Further our model differentiates between operational and clinical contacts. The first can be taken care by administrative personnel. We believe that a lot of scarce clinical resources could be taken into better and more efficient use, if they could be freed from routine operational communication through sophisticated contact routing systems. We presented some well-known international examples, and our own case study from the city of Turku. This empiria shows that current contact center solutions heavily depend on the phone as a communication media, and that computer-based communication is not yet supported. Even basic computer-telephony integration seems hard to implement. As it comes to work-flows in health care, we feel that contact centers are not able to change them profoundly. Rather they have the typical effects most often attributed to telecommunication: the electronic communication effect, the electronic brokerage effect and the electronic integration effect [22]. The electronic communication effect refers to faster transactions: instead of visiting a general practice the customers can get many services through the electronic contact. The best visit to a general practice is a refrained visit. The electronic integration effect is achieved through the central patient record systems: all the needed information is easily accessible, and the patient does not have to endlessly cruise in the service network because of missing information. The electronic brokerage effect materialises in the fact that the patient has through the faster processes it easier to ask for alternative opinions. Our own case study allowed us to dig into the background issues of implementation too. We could

0-7695-1874-5/03 $17.00 (C) 2003 IEEE

Proceedings of the 36th Hawaii International Conference on System Sciences - 2003

sense a general feeling of getting tired: it is not long ago electronic patient systems were implemented, and their use is not yet on a standardized routine level. It might be too early for the health care professionals to aspire at sophisticate contact methods to customers. One issue that emerged too is that of external extra finance and support. Public health care organizations especially are too used to get external extra finance for IS development projects. This has resulted in a situation, that they no more understand and consider IS development as a normal activity in any organization. If external motivation factors dry out, too little happens. Opponents towards the introduction of IS into the health care have a too effective and easy-to-use weapon: appealing at security and privacy issues can ruin any information system project, or at least make the introduction of the systems too complicated and expensive to be worth the effort. Unsettled legislative ramifications and business processes add up to the confusions. While we wholly understand and underwrite the importance of privacy and security, we believe that in most cases turning the systems into computers away from paper-based media already as such will significantly improve both security and privacy. And at the very end, privacy in health care too is at the hands of ethical professional codes adopted by the professions active in the field. One can see that we live a period of different projects and trials. No wonder the customers are too confused. The only standard way of contacting doctors seems to be that of personal general practice consultation. Take private banking as an example: though more easy in context, it has taken over 20 years for bank customers to learn to use new media, and the service structures still are in a constant flux. Many customers, especially the older generation, have decided to keep out of electronic media in total. This is too a problem in the health-care. Heavy-users of the services, the older people, are most unlikely to adopt to computer usage. The computer-literate younger generation again is not in a bid demand for health care services.

[5]

[6]

[7]

[8]

[9] [10]

[11]

[12] [13] [14] [15] [16]

References:
[1] Anton, J., "The past, present and future of customer access centers," International Journal of Service Industry Management, vol. 11, No 2, 2000, pp. 120-130, 2000. Arnbrak, J., "Trans-Border Communications Networks: Technology-Driven or Social Innovation?," European Management Journal, pp. 330-337, 1988. Bolisani, E., "Communication Processes and Electronic Communication: A Framework for the Assessment," presented at 7th European Conference on Information Systems (ECIS-99), Copenhagen, Denmark, 1999. Cain, M. M., Sarasohn-Kahn, J., and Wayne, J. C., "Health e-People: The Online Consumer

[17]

[2]

[18] [19]

[3]

[4]

Experience," California Health care foundation August 2000 2000. Chau, P. Y. K., "Reexamining a Model for Evaluating Information Center Success Using a Structural Equation Modeling Approach," Decision Sciences, vol. 28, pp. 309-334, 1997. DElia, G., Branin, J., Adams, C., Beath, C., Rohde, N., and Straub, D., "Issues Relating to the Implementation and Management of an Integrated Information Center," Journal of the American Society of Information Science, vol. 42, pp. 147151, 1991. Daft, R. L. and Lengel, R. H., "Organizational Information Requirements, Media Richness and Structural Design.," Management Science, vol. 32, pp. 554-571, 1986. Dennis, A. R. and Kinney, S. T., "Testing media richness theory in the new media: The effects of cues, feedback, and task equivocality," Information Systems Research, vol. 9, pp. 256274, 1998. EITO, "European Information Technology Observatory 2001," European Economic Interest Grouping (EEIG)., Frankfurt/Main 2001. El Shinnawy, M. and Markus, M. L., "The poverty of media richness theory: Explaining people's choice of electronic mail vs. voice mail," International Journal of Human Computer Studies, vol. 46, pp. 443-467, 1997. El-Shinnawy, M. M. and Markus, M. L., "Media Richness Theory and New Electronic Communication Media: A Study of Voice Mail and Electronic Mail," presented at International Conference on Information Systems, Dallas, Texas, 1992. George, S., "NHS Direct audited. Customer safety, but at what price," British Medical Journal, vol. 324, pp. 558, 2002. Greiner, L., "Single point of contact," Computing Canada, vol. 28, pp. 14-15, 2002. Hamilton, T., "CTI, Internet to lead 'virtual organization' charge," Computing Canada, vol. 23, pp. 38, 1997. Kinder, T., "The use of Call Centres by local public administrations," Futures, vol. 33 (10) 2001, pp. 837-860, 2001. Klok, J., Pauli, E., Roode, R., P., S., Stijger, K., Thiadens, T., and Schut, K., "Handling a 20 000 Calls-a-day Telephone Environment: The Case of a Service Organization.," International Journal of Information Management, vol. 15, pp. 389-400, 1995. Lagendijk, P. J. B., Schuring, R. W., and Spil, T. A. M., "Telecommunications as a Medicine for General Practitioners," in Strategies for Healthcare Information Systems, R. Stegwee and T. A. M. Spil, Eds. Hershey: Idea Group Publishing, 2001, pp. 114-125. Lee, L. T. and LaRose, R., "Caller ID and the Meaning of Privacy," The information society, vol. 10, pp. 247-266, 1994. Lincoln, T. L. E. D. J. W. W. H., "The electronic medical record: a challenge for computer science to develop clinically and socially relevant computer systems to coordinate information for patient care and analysis," The information society, vol. 9, 1993.

0-7695-1874-5/03 $17.00 (C) 2003 IEEE

Proceedings of the 36th Hawaii International Conference on System Sciences - 2003

[20] Lynn, E., "NHS Direct Online explores partnership with other health organisations," British Medical Journal, vol. 324, pp. 568, 2002. [21] MacDonald, K., Case, J., and Metzger, J., "EEncounters," California Health Care Foundation November 2001 2001. [22] Malone, T. W., Yates, J., and Benjamin, R. I., "Electronic Markets and Electronic Hierarchies: Effects of Information Technology on Market Structure and Corporate Strategies," Communications of the ACM, vol. 30, pp. 484497, 1987. [23] Ragupathi, W., "Health Care Information Systems," Communications of ACM, vol. 40(8), pp. 81-82, 1997. [24] Rheingold, H., The Virtual Community: Homesteading on the Electronic Frontier. New York: First HarperPerennial, 1994. [25] Rice, R. E., "Task Analyzability, Use of New Media, and Effectiveness - a Multisite Exploration of Media Richness," Organization Science, vol. 3, pp. 475-500, 1992. [26] Richardson, R., Belt, V., and Marshall, J. N., "Taking Calls to Newcastle: The Regional Implications of the Growth in Call Centres," Regional Studies, vol. 34, pp. 357-369, 2000. [27] Robb, D., "Help desk gets a life-line," Computerworld, vol. 35, pp. 50-51, 2001. [28] Rowe, F. and Struck, D., "Cultural values, media richness and telecommunication use in an organisation," Accounting, Management and Information Technologies, vol. 9, 1999. [29] Schmitz, J. and Fulk, J., "Organizational colleagues, media richness, and electronic mail: A test of the social influence model of technology use," Communication Research, vol. 18, pp. 487523, 1991. [30] Straub, D. W., DElia, G., Branin, J., Adams, C., Beath, C., and Rohde, N., "A Model Academic Integrated Information Center," Journal of the American Society of Information Science, vol. 42, pp. 143-146, 1991. [31] Suomi, R., "Leapfrogging for Modern ICT Usage in the Health Care Sector," presented at Proceedings of the Eighth European Conference on Information Systems, Vienna, 2000. [32] Suomi, R., "Streamlining Operations in Health Care with ICT," in Strategies for Healthcare Information Systems, T. A. Spil and R. A. Stegwee, Eds. Hershey, PA: Idea Group Publishing, 2001, pp. 31-44. [33] Suomi, R., Thkp, J., and Holm, J., "Organizational and information system metaphors in the health care sector - from harmonised value chain to realistic market models," presented at The 8th European Conference of Information Systems, Bled, Slovenia 27-29.6.2001, Bled, Slovenia, 2001. [34] Suomi, R., Thkp, J., and Holm, J., "Outsourcing of health care information systems why and why not," in Health and Wealth through Knowledge. Information System Solutions in the Health Care Sector, R. Suomi and J. Thkp, Eds. Turku: Turku Centre for Computer Science, 2001, pp. 65-75. [35] Sussman, S. W. and Sproull, L., "Straight talk: Delivering bad news through electronic

communication," Information Systems Research, vol. 10, pp. 150-166, 1999. [36] Utbult, M., Nthlsa. Internetpatiente mter surfande doktore - uppstr konfrontation eller samarbete? Stockholm: Reldok och KFB Kommunikationsforskninsgberedningen, 2000. [37] Zbar, J., "Controlling the cost of remote support," Network World, vol. 19, pp. 23, 2002.

0-7695-1874-5/03 $17.00 (C) 2003 IEEE

10