A technological solution
To balance productivity, ease of use and cost-efficiency, BMC's Medical MISU used a communications development platform from Envox Worldwide to create an automated, phone-based program that essentially enables virtual health care visits. The system combines interactive voice response (IVR) with sophisticated scripting and uses a series of complex decision-making algorithms to enable effective automated phone-based interaction. The voice on the phone emulates what a health care professional -- a doctor or nurse -- would say and do in a conversation with a patient in the office.

This last point is critical. Systems that employ the much-loathed "press 1 now" model for entering information tend to alienate patients. The more advanced IVR model used by the MISU employs speech recognition technology that provides the patient with spoken cues and then reacts to their answers. Patients don't harbor the illusion that they're talking to a live person, but the conversational format is natural for the patients and easier to use than lists of numeric responses. The interactive voice responses also give the system a more professional veneer than keypad responses, which are associated in most peoples' minds with commercial self-service applications.

The MISU team recently launched a system, which screens people at risk of substance-abuse problems, for the Massachusetts Department of Health. Funded by the federal Substance Abuse and Mental Health Services Administration, BMC's effort is one of eight such projects nationally and the only one that employs computer and voice technology to deliver an automated screening and treatment program. Hosted at BMC, the screening system takes preliminary data from medical practices and uses it to conduct phone-based screenings of primary care patients for undiagnosed substance-abuse problems. It compiles the screening results in reports for the clinicians. The system enables health care providers to screen hundreds of English- or Spanish-speaking patients per day.

"Thousands of people are pre-screened every week, and as many as 20 percent of these screenings can be positive," said Amy Rubin, a clinical psychologist and member of the MISU development team. "It would be prohibitively expensive for health care providers to screen these patients themselves, but early detection is critical for people in the beginning phases of addiction. With the voice-activated system, we can get to them right away."

The trial results to date are highly successful. The IVR system functions as an adjunct or assistant to the doctor. It diagnoses unrecognized or poorly treated alcohol and drug problems. It would be time-consuming for a physician or other office staff to do such a screen, time that could be spent dealing with patients' existing medical problems. And patients benefit because health care problems that neither they nor their physicians are aware of are detected, which is the first step to getting effective treatment.

The results
Doctors want to talk to their patients more often. They want to ensure patients are doing well, that they are engaging in self care, taking their medications properly, engaging in proper diet practices and so on. This is a doctor's mission and pledge, and, in an ideal world, doctors would be able to see their patients as often as the patients' conditions require. The realities of economics and modern life, however, don't favor that scenario. Doctors have far-flung responsibilities. Patients can't take time out of every day to visit the office, and must often pay for office visits themselves.

Solutions such as the TLC system bridge the gap between needs and realities. Information gathered via the TLC can easily be passed on to the doctor where it can quickly be reviewed and acted upon. This model of care improves patients' conditions by detecting new or worsening medical problems, alerting doctors and other clinicians about them, and by improving the patients' self-care practices. It highlights the fact that medical problems frequently go unnoticed or unresolved between office visits. It helps answer questions that couldn't be answered before. The information may result in a referral -- or a more immediate follow-up visit. Whatever the situation calls for, the doctor at least has a better tool for understanding what needs to be done.

Blood sugar levels don't rise and fall based on scheduled office visits. Medication side effects happen immediately, not conveniently before your next doctor's appointment. Advances in computerized voice production and speech recognition technology will enable health care providers to extend their reach to improve patient care and deliver demonstrable results for not only patients, but for their physicians as well.

Dr. Friedman is chief of the Medical Information Systems Unit at Boston Medical Center and professor of medicine and public health at Boston University.