Do We Need Triage in Primary Care? (14 mins)

Have you noticed how busy the clinic waiting rooms are becoming? As the largest living generation retires from providing care and seeks to receive it, our primary care models are experiencing new challenges. This episode seeks to focus our efforts on an improvement mindset as we manage the surge of patients.
Key Points:
-Blocking the Door
-Black Friday in Healthcare
-Primary Care Triage

References:
-Shen, Fan (2004). The Barefoot Doctor. Gang of One. University of Nebraska Press.

Transcript

She giggled mischievously. “I block the door so the doctor can’t walk out on me!”

I was with a group of savvy women who were sharing tips on solving their family’s healthcare problems, and this one made us burst into laughter. The author of this method held her hands out in a solid “stop” motion, squinting over her bifocals with a determined look on her face, effectively barring the door when the doctor tried to leave after ten minutes, which is about the length of time a primary healthcare appointment can last and still remain profitable with most insurance and government reimbursement plans. Primary care doctors are under constant pressure to maintain this short duration by their clinics.

While some looked shocked at the drastic measures my friend took, everyone could relate to a long wait at the clinic with little to show for it in appointment.

Another friend went to have a routine office procedure done and found the waiting room unusually busy. “Did a doctor call in sick, or something?”

“No, we just had a surge in patients with this diagnosis. The Baby Boomers are retiring and now they need care, but we’re just not sure how we’ll take care of them all.”

As we move from having an excess of specialists to a relative deficit in providers, I wonder if it’s time to change the way we approach the traditional office visit.

In rural healthcare, I have heard stories of family doctors making house calls. But in cities, where needs increase with population density, the approach has to be different.

Likewise, anyone who has worked in a high-need, low-resource environment knows that a needs assessment is critical to running operations. The approach is entirely different. You don’t have time to sit with everyone and hear about all of their potential problems because too many people would go without any care at all. 

I’d like to consider an analogy. All of us have experienced a website crash in some form or another. One of the reasons for a website crash is something called a Denial of Service Attack. A Denial of Service Attack occurs when a large group of bots swarm a site at the same time. Normally, each request signals a script to run that tells the machine to load a page or an image or something, and each script requires some bandwidth on the network. More demands on bandwidth will slow down a network, but a swarm of demands can break it. When the network is flooded with requests, it can’t load the scripts and the network crashes. It’s a disastrous form of cyberattack that often requires a complete reboot of the website, which in turn can result in customers leaving, lost orders, and lost data. That’s why a lot of websites will send an alert or have some sort of automation to shut down temporarily when there is a surge in requests, which can protect a site from data losses and maintain its functionality for the long-term. 

Another example would be Black Friday sales. If everyone tries to get in the door at once, customers can get hurt, people who are vulnerable can get left behind, and sometimes a customer is even trampled. How did the consumer industry handle this risk? By putting someone like a security guard at the front door to control the flow of people.

No one wants to take a number and sit, but no one wants to be trampled either. Some places allow for digital check-ins and others add items of interest to browse while you wait (that stack of expired magazines in the waiting room for instance), but no one can effectively handle a surge of people with the same need at the same time without forming lines and waitlists.

It is critical to prioritize needs. We bristle at that notion, but it does have relevance in the medical world today. For example, a simple assessment and some experienced prioritization can help determine if the rash on your arm is something that requires an office visit (such as possible Lyme’s disease) or something that can be treated with some over-the-counter cream (like a dust allergy reaction).

In reality, I don’t think a waitlist alone is helpful in healthcare. That is the model that governments around the world use for single-payer, national health systems, and it results in all kinds of complaints and delays in care. 

The missing element is an informed and well-defined triage completed by an expert. And the expert part is really critical. If you put a unit secretary on the phone to decide if that rash needs a closer look, you’ll either end up with everyone swarming again (better safe than sorry) or a blockade at the door that keeps everyone out, regardless of need. Or, in the worst-case scenario, a non-expert could offer medical advice that leads to worse harm.

The book Gang of One by Fan Shen offers a glimpse of non-expert providers in primary care. He describes his training after being selected for the Barefoot Doctor program in 1960s Communist China. The medical doctor program took three-months of training; only two of which included medical training – the rest was ideological training to ensure that even bad doctors would be good members of the Communist party. After this brief training, he was sent out into a rural area with no mentor or reference and only a white medicine box, containing a roll of bandages, herbal cough medicine, and acupuncture needles. Any other supplies were contributed from his own pocket. He then dealt with septic shock, hemorrhages, traumatic injuries, and amputations using only the books he purchased and the two-months of observation he received.[1]

So when we talk about identifying more affordable and widely available providers for primary care, this is what I think of and it makes me shiver. When the patient volume is increasing and the provider volume is decreasing, we can either lower our expectations for quality in care – i.e. the communist barefoot doctor version of primary care – or we can funnel and organize our care model using prioritization and logic. This is why I’m sharing an entire podcast about primary care triage – not because I want to cheapen our current experience, but because I am afraid of the solutions I have heard of being offered to deal with the generational gap. 

But using a logical approach and prioritizing needs could offer a solution that adjusts our expectations for primary care and leverages home and online patient education more effectively. Using a defined method of triage can also help keep appointment times open for the patients who most need it, like the ones who recently discharged from the hospital with changes to their medications.

Many of us have less-than-ideal experiences with calling nurse lines and telephone triage, but recently, our community came to depend on a public health phone line to help determine if a loved one might have COVID and required testing. In a time when public information was scarce, it was a lifeline for those who were questioning whether their husband’s last sneeze was a sign of severe illness or just seasonal allergies. The public health professional asked critical questions about exposure and risk and put many people at ease that they did not need to go to the Emergency Room, and gave them confidence to identify the signs, symptoms, and risk factors they should consider in the future. It was an incredible educational tool as well as a triage system.

Why did it work so well? 

Well, for one thing, it was problem-focused, which allowed some specialization of knowledge, rather than a generalized answer that you could get from a random health website. I could see the benefits of system-based triage where a mid-level with gastrointestinal experience took related GI calls, and someone who is set up to receive pictures of skin problems could receive the skin-related questions and photos. The scripted questions would ensure a full assessment without restricting speech to the script alone, and the technology would be geared to the needs of that system type.

Another reason it worked well is that it was local, and these healthcare professionals were aware of case counts and patterns, which meant they could identify when a flu outbreak was complicating their potential COVID calls. Making local data available then is an essential data source for primary care triage to help providers identify likely scenarios and potential risk factors.

These are just a few examples of ways that we can use smart data and clearly defined roles to help primary care providers thrive in these changes rather than despair from the overwhelming load.

In Quality for the Rest of Us, I wrote about my ABC method for prioritizing problems based on whether they were Acute, Big, or Costly. An acute problem is one that is severe or unstable. A Big problem is typically widespread or repeated, and a Costly problem is one that incurs significant damage, risk, or loss.

In healthcare, every Emergency Room physician uses something similar to triage patients and identify the most de-stabilizing problem. The goal is to stabilize the patient and help them return home, which means that follow-up is necessary, but care is appropriate for the acuity of the problem.

Primary care on the other hand manages everything in between, from directing patients to the Emergency Room, advising someone to stay home to rest, or referring an injury to a consulting surgeon. In fact, a heavy burden rests on primary care to coordinate care throughout the system. This is the real burden of primary care – it’s not the patient complexity or the volume or the staffing issues, it is the burden of working in a disorganized and complicated system. This, too, is the golden opportunity, because asking a physician to make phone calls all day for referrals is a waste of their expertise, but focusing their pool of visits to high-priority needs and setting up automated referral and appeal call systems that calls the doctor when the line is no longer on hold[sp1]  would be a simple tool that comes at a fairly low cost and would organize a provider’s time more effectively.

Effective primary care triage would automate the tasks that come from the healthcare system itself. Tasks like calls to agencies, forms, refill requests and DME reviews – any demands that are repetitive and do not directly deliver value to the patient’s health would be an opportunity for automation and machine learning to filter and identify the cases that need some extra attention and the ones that are likely fine. Perhaps even common patient discussions like diabetic footcare or medication instructions could be provided through digital media such as video could be offered during digital check in to save time during the appointment itself. All of these options would allow primary care to focus on patients again. It doesn’t mean that we’d all have half-hour appointments with our doctors’ full attention again, but it would mean that the brief conversation in the room would be about my health and yours rather than paperwork and red tape.

No matter what path we take, the increased demands placed on physicians caused by the generational gap and a battered healthcare system is going to necessarily shift our expectations. We may need to ask patients what their priority problem is, and we may need to assess which problems are most problematic to their, and perhaps arrange group assessments to meet the needs of the population.

Most of all, we will need to assess our own needs and become more innovative in our solutions.

How do you anticipate managing this demographic shift?

 I’d love to hear your thoughts.

[1] Shen, Fan (2004). The Barefoot Doctor. Gang of One. University of Nebraska Press.

 [sp1]Would that just interrupt an appointment? Couldn’t staff do this?