No one person invented telehealth nursing or telephone triage, says Lois Scott. It was an idea that had been percolating in the minds of a number of people in the United States and Canada. For Scott, the idea grew from her work as an ER nurse manager in New Brunswick and from her Master's thesis. "Why," she wondered, "would someone with non-urgent symptoms go to a hospital and wait three to four hours, only to find out they didn't need to be there in the first place?"

The main reason, Scott found, was uncertainty about the symptoms and anxiety. In Scott's study, she found that, in many cases, the anxiety was as high as that reported in other studies for people with diagnoses of heart disease or cancer. She discovered, however, that individuals who received a four- to five-minute information session about their symptoms, and were reassured that they were neither life-threatening nor serious, became far less anxious.

Scott's idea was to use the poison control center model. This model, which had been around since the 1950s, successfully provided poison information over the telephone, reassured people that they did not need to go to an ER and promoted self-care.

Scott left the ER in 1993 and took a job with the New Brunswick Department of Health & Wellness, where she promoted her telehealth idea. In 1996, Clinidata Corporation received the contract to set up New Brunswick's telehealth service. They recruited Scott and she is now the company's executive vice president and general manager. Clinidata's nurses currently provide telenursing advice to over 2 million callers each year.

It is reminiscent of a stock market report: NCQ 10 ADQ 272 LLQ 505 (and climbing) ASA 756 . But this electronic board above the nurses' computer stations is not showing you how your investment portfolio is doing. It's how the staff at Telehealth Ontario's Toronto call center is doing:

Originally, says Scott, telehealth nurses spent a lot of time referring callers to 911; now, 911 refers callers to them. Of calls, approximately 44% are self-care; 40% are referrals to a family practitioner or clinic; 12% to 14% are referrals to an ER; and 2% are direct transfers to 911.

Not surprisingly, the phones are busiest in the evenings and on holidays. The busiest months are January to March – cold and flu season. But even during typically busy months, there can be surprises: in January 2003, the Norwalk virus outbreak doubled the normal call volume of 4,000 calls to 8,000 calls.

About 70% of calls are from women, and 30% are from men. Often it's the women calling for their children, but, the nurses laugh, they call a lot for their husbands, too. "Then," says Scott, "it's 'Can your husband speak? Well, put him on the phone!'" They also prefer to speak directly with children, who, from age four or five, can articulate their symptoms.

And 90% of callers say they will comply with the nurse's advice. This, for Scott, is a testimony of the credibility of nurses as a source of health information.

Scott enumerates five skills for success as a telehealth nurse: excellent communication skills, strong clinical judgement, critical thinking, ability to multi-task, and comfort with technology. Nurses who don't do well, says Scott, are those who miss hands-on contact with patients and those who cannot handle bouts of routine, such as receiving 30 identical calls during flu season.

Nurses must complete a month of training, which includes orientation to telehealth's computer system, listening to sample calls, handling incoming calls with a coach, and receiving coaching on recorded calls. The competencies for telehealth nursing are based on those of the College of Nurses of Ontario, and the QM is exactly what would be found in a major hospital.

The nurses enjoy telehealth for several reasons. On the telephone, they aren't interrupted – they get one-on-one time with their patients. They feel appreciated by both the callers and the management. Every call provides them with the opportunity to teach. Manjit Dhanoa-Yasi, a Master's prepared staff educator who still works casual hours in a teaching hospital, says she likes the constant variety.

In New Brunswick, the telehealth service has combined with public health, and, therefore, also handles information about poison, prenatal care, organ and tissue donation, communicable diseases (e.g., rabies and West Nile virus), and addiction referrals. This blend has been particularly effective. Not only will public-health queries now be answered any time (before they were only answered during weekday business hours), but outbreaks are being noted quickly. Scott cites the example of several individuals in one small community calling in about diarrhea. The senior nurse monitoring the center noted the quantity of similar calls, and, when she investigated, she discovered that there was an E. coli outbreak in the community.

Future plans include creating web-based health information and "webinars" and building relationships with schools for lunchtime online health information sessions, where students can watch and listen and then email questions to a nurse. Another is for tele-home care. A patient would still have a home care nurse or a primary care doctor, but tele-home care would allow for close monitoring and reassurance. In American pilot projects involving COPD and CHF patients, tele-home care lowered hospital visits by 30% and 32%, respectively.

Though telehealth is now nursing-driven, Scott hopes to bring other disciplines, such as pharmacy and dietetics, into the fold. And they're hoping to go global: Clinidata has had inquiries from countries as diverse as Australia and Costa Rica about providing telehealth services. One of the beauties of a call center is that it can take calls from anywhere.