The report is a product of the VA/HSR&D Evidence Synthesis Program.
Effectiveness of Remote Triage: Systematic Review
The US healthcare system currently faces several challenges including caring for an increasing elderly population, an increasing patient population with multiple chronic conditions, and an uneven distribution of primary care providers. Additionally, many patients experience multiple barriers to receiving timely care, such as financial and logistical impediments. Such access challenges lead many people to seek acute or chronic care in emergency departments (EDs) when their needs might have been addressed in a primary care setting. Increasingly, acute care visits take place outside of the primary care setting. One way of providing patient access to the appropriate level of care is through technology-based systems that facilitate remote decision-making about healthcare.
Remote triage is defined as making clinical decisions in the absence of a face-to-face encounter. Remote triage modalities offer the potential for improved access to on-demand healthcare.
VA's Evidence Synthesis Program (ESP) Center in Durham, NC examined the impact of remote triage on outcomes that were meaningful to VA operations stakeholders (i.e., VA's Office of Connected Care), clinicians, and policymakers and explored emerging practices for implementing a remote triage system. Investigators searched MEDLINE (via PubMed), EMBASE, and CINAHL from inception through July 27, 2018; they also examined bibliographies of recent reviews for additional relevant studies. The literature search identified 11,939 relevant articles. Of these, 9 were identified as relevant studies assessing the effectiveness of remote triage and 32 studies addressing emerging practices for implementing remote triage systems. No studies specifically addressed Veterans or were conducted in the VA healthcare system. Also, no studies reported modalities of remote triage other than telephone.
Summary of Findings
Effectiveness of Remote Triage
While the current evidence on the effectiveness of remote triage is limited and of low to moderate certainty of evidence (e.g., few studies, risk of bias issues), the findings of this systematic review hold insights for those wanting to implement such a system.
- The majority of studies did not demonstrate a decrease in primary care or ED use.
- The evidence suggests that local, practice-based telephone triage services have higher case resolution outcomes and refer fewer patients to emergency or primary care services compared with regional/national telephone-based remote triage.
- Remote triage appears to be safe, but the identified literature was very sparse with only two identified studies.
- The impact of remote triage on patient satisfaction was heterogeneous, and may be influenced by the degree that patients perceive the received triage service to differ from their expectations of care needed at the time of contact (e.g., the caller expects to receive a same-day appointment rather than after-hours advice from a non-clinical call handler).
- Investigators found no difference in the overall cost of care, but the literature was very limited.
Emerging Practices for Implementing Remote Triage
No studies identified best practices, but focused instead on considerations for emerging practices when implementing a remote triage system in a large-scale healthcare system such as VA.
- The execution of remote triage influences the entire healthcare system. Implementing a remote triage service is a multifactorial process. There are several key findings for emerging practices for the implementation of a remote triage system that may improve efficiency and outcomes.
- At the individual level, considerations must be made for individuals serving as remote triage staff, including a work environment that supports physical and emotional wellbeing, patients who use triage, and ancillary staff who assist in the daily functioning of triage.
- At the clinic level, considerations must be made for how remote triage influences the clinic workflow, scheduling and availability of appointments – and workload among clinical and non-clinical call handlers.
- At the system level, considerations must include how remote triage is influenced by and how it influences the availability/accessibility of healthcare services (e.g., clinic appointments, ambulance services). Attention also must be paid to the healthcare resources in the internal environment (i.e., access to a clinical-decision support software) and in the external environment (i.e., healthcare resources outside remote triage system; distances to care) that impact remote triage decisions and the patient’s ability to adhere to advice.
- Purposeful planning prior to, and throughout the implementation of remote triage is important in ensuring the success of remote triage.
- Educating patients and their family members on the purpose of remote triage may promote the appropriate use of remote triage services.
Implications for Current Practice and Policy
Remote clinical triage centers are an increasingly prevalent feature of healthcare delivery, particularly among large healthcare organizations. An important goal for remote clinical triage centers is the ability to provide case resolution during the first contact. Such resolution means that a telephone call is managed without triage for other services – or that a caller is connected with the appropriate individual with only a one-call transfer. An important policy consideration is should the goal of a remote triage system be to resolve cases without triage to in-person services as opposed to determining the appropriate triage destination for that patient? Further, designing a remote triage system has implications related to staffing (clinical vs nonclinical staff), setting caller expectations, and other considerations. For example, having a clinician (e.g., RN) as the first point of contact could allow for dispensing of medical advice, reducing the need for further triage. An alternative staffing model might involve training non-clinicians to make triage decisions (at sites of care that do engage clinical staff). These different design options come with implications for first-contact outcomes and staffing costs. Findings from this review provide insights into considerations for implementing staffing structures to optimize outcomes.
Multi-modal contact is another important consideration for VA when designing a remote triage system. The ability to enter the triage system by means other than a telephone call will be important to study and understand. Smartphone-based mechanisms such as texting, messaging, and chat as alternatives to telephone calls may be a preferred means of contact for many Veterans. While the mode that Veterans use to contact the system may be transparent to the recipient, it is nonetheless important to also consider how the recipient receives these requests and what the expectations are for processing requests.
Research Gaps/Future Research
There is increasing interest among patients and even healthcare systems to provide multiple modes of contact; however, the current comparative literature addressed only telephone contact and in-person modalities. Future interventions should focus on modes of remote triage delivery in addition to telephone (i.e., video, web, mobile applications), the impact of medical record access, the critical elements in support of triage systems, staffing models and experience, and elements of the CDSS (Clinical Decision Support System) that support triage operations. Potential future comparators should include head-to-head comparisons of triage modalities, staffing models, organizational levels, and remote triage features. More research also is needed on the outcomes evaluated in this review. Suggested settings for future research include VA or similar large healthcare systems.
Rushton S, Boggan JC, Lewinski AA, Gordon AM, Shoup JP, Van Voorhees E, Whited JD, Alishahi Tabriz A, Adam S, Fulton J, Kosinski AS, Van Noord MG, Williams JW Jr, Goldstein KM, Gierisch JM. Effectiveness of Remote Triage: A Systematic Review. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #09-010; 2019.
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