By the time the patient called back and reached an advice nurse, she was fighting so desperately for breath that Erickson and a doctor told her to go to an emergency room.

Relatives of another patient, who was just out of the hospital after heart surgery, were repeatedly told they'd have to call back the next day because no one could answer their questions about when the man should start taking his post-hospital medication, Erickson said.

"The family kept pushing, pushing to get a nurse," Erickson said, and were hugely frustrated when they finally got through. She helped them connect with a doctor who said the man should start taking his medication that evening.

Kaiser contends that scripts make better medicine – as well as happier patients.

"Nurses, believe me, I love nurses, but on a telephone evaluation they tend to be very conservative," said Levine.

Clerks get some training

Nurses spend more time on the phone with callers, which can frustrate the patient, she said, and the wait to reach a nurse is also longer.

"If you have a bunion and want to see somebody, how is a nurse going to help you with that decision?" Levine asked.

Kaiser gives nonmedical people who answer phone lines a few weeks of training and pays them $15 to $16 per hour. It pays about $50 an hour to the advice nurses to whom more complicated calls are routed.

Call centers in San Jose, Vallejo and Sacramento employ 1,200 front-line phone workers, 800 nurses and a small team of doctors.

Patients who specifically ask to talk to a nurse are transferred to one, Levine said, and clerks will type in a message for patients who want to send a note to their doctor. Most of those messages are answered within 24 hours, she said.

To further ensure safety, Kaiser has a list of 15 "emergent concerns," such as chest pain, trouble breathing and other potentially dangerous conditions that will get a caller switched immediately to a special line that nurses answer quickly, usually in 10 to 15 seconds.

A committee of doctors, nurses and others reviews the hundreds of scripts regularly, looking at complaints, new research and patient outcomes, before revising dialogues.

The state's investigation so far has not turned up any "substantiated" safety complaints, Levine said, and the call center has not been the target of any state fines.

The call center did not exist in 1996, when a woman's death led to a $1 million state settlement, assessed after Kaiser was accused of several missteps, including handling her calls inappropriately.

Now, the state Department of Managed Care is trying to determine whether Kaiser is following the 2003 law, which a state attorney calls confusing.

"Booking an appointment is in a gray area," said Amy Dobberteen, the department's chief of enforcement.

Along with those who wrote the law, though, some Kaiser nurses see the rule as much more black and white.

HMO sought bill changes

Clerical personnel can do nonmedical tasks such as giving directions to a clinic or pharmacy, or booking appointments for physicals or other regular health checks, they say. The first-line clerks should not make appointments for people who aren't feeling well.

"In every other job I've had as an advice nurse, if a patient has a symptom, they're supposed to be transferred directly to a nurse," Erickson said.

Bowen had very specific dialogue with Kaiser while the Legislature was debating her bill, Senate Bill 969, which aimed to limit what call center personnel can do.

The HMO was so worried the bill could prevent its use of scripts that it wrote Bowen asking her to amend it. It gave her draft language that would have allowed its style of scripted conversations. She refused to amend the bill.

After the measure passed, Kaiser wrote to then-Gov. Gray Davis, asking him to veto it, saying it would create confusion over proper roles of telephone staffers. Instead, the governor signed it.

He did note that call center workers still could make appointments, but he never explained under what circumstances.

Despite the repeated concerns that Kaiser raised about the measure potentially stopping its use of scripted conversations, it has continued to rely on them.

Call The Bee's Carrie Peyton Dahlberg, (916) 321-1086.