office visits, many health plans have established telephone advisory programs, staffed primarily by nurses, to provide patients with information, assessments, and recommendations for routine medical problems. For medical and other emergencies, the 911 system works from any telephone to put people in touch with dispatchers who assess the nature of the emergency, send medical or other assistance as indicated, and provide medical instructions (e.g., for cardiopulmonary resuscitation) when necessary.

In addition to person-to-person communications, automated telephone services are used in various ways. For example, interactive voice response systems allow individuals to initiate calls and respond to recorded questions using a touch-tone telephone. Such systems have been used to test automated telephone screening for depression, with questionnaire score provided to callers along with toll-free follow-up telephone numbers (Baer et al., 1995). A different kind of automated arrangement provides for scheduled, automatic calls to patients. Patients can then respond by using a touch-tone telephone to enter basic medical information or by using a special device attached to the telephone to transmit physiological measurements. Evaluations of these kinds of program are discussed in Chapter 5.

One of the oldest telephone-based monitoring programs has been operated by Veterans Affairs Medical Centers in San Francisco and Washington, D.C. They have acted as pacemaker surveillance centers since 1982, and these centers now monitor over 11,000 patients both at home and away from home (VA, 1996). (Because pacemakers are programmed to change their normal operating frequency when batteries run low and because an electrocardiogram can detect this problem, a device attached to a telephone can transfer an ECG reading to the centers, which can thus identify this problem long distance.) Other monitoring systems rely on radio-based technologies to raise an alarm if a patient does not check in on a regular basis or if a patient triggers the alarm following an emergency such as a fall. Patients with heart disease can carry beepers that allow them—if they experience symptoms—to transmit a 12-lead electrocardiogram using ordinary phone lines. A commercial service in Israel claims 30,000 subscribers for such a system (Carthy, 1995).

Video-based home health options are also varied but less common. Many are still in the testing stage. Patients may sit before video cameras at scheduled times to talk with clinicians and, perhaps,



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