One of the strengths of our current healthcare system is that the critical task of routing patients to appropriate specialists is performed by primary care physicians. They are also often on call to respond to inquiries about urgent care or referral to an emergency room.
How patients are routed to appropriate care is a crucial aspect of running an efficient medical system. As we consider changes to our healthcare system, it is vital to note the importance of accurate and timely routing, to focus resources on keeping this process reliable, and to improve upon it where possible.
Routing is known in medical circles as triage. Unlike the triage in disaster or wartime, triage in a modern medical setting simply refers to the act of directing patients to the appropriate care.
Today, most routing occurs in the primary care physician's office or through the physician's after hours call-in system. This process often works smoothly, with knowledgeable family physicians, internists or pediatricians assessing patients in a timely manner and routing them appropriately. They may treat a patient directly or refer to an appropriate specialist or clinic.
When care is required after-hours and the PCP is not available, patients call a service to reach the doctor on call. Some medical offices provide extended-hour urgent visits. Some practices and insurance agencies also provide 24-hour phone access to medical professionals through a “nurse line.” These call-in services can provide feedback to the patient as to whether he or she should go to the emergency room, or whether their condition can wait.
However, the medical routing system doesn’t always work efficiently.
Individuals who are uninsured, or who do not have a primary care provider, often resort to the emergency room for non-emergency care. Without a PCP to act as a router, and without access to a 24-hour phone support, these individuals' options are limited. If their medical problem occurs at night, or if they can’t make it to a walk-in clinic during the clinic’s hours because of work, childcare, or other responsibilities, the emergency room becomes the only option. This puts a huge strain on the emergency care system, since a large portion of its resources must be devoted to treating or routing these cases rather than on the truly urgent ones.
Even for people with insurance and a PCP, the intake system often doesn't work well. The wait for an initial appointment with a family physician averages 20 days in the United States as a whole. According to a 2009 survey, the average wait time to see a family practitioner in Washington, D.C., was 30 days; in Los Angeles, 59 days and in Boston, 63 days.
This delay in the initial care and routing process indicates that something is amiss with the intake system. The influx of patients seeking initial evaluation and referral to specialists overtaxes the primary care system. What’s more, delays in diagnosis can have serious health consequences.
The initial triage decision falls to the receptionist, who is generally unprepared to properly make such decisions. When the doctor is too busy to see everyone who wishes to be seen, the receptionist is put in the position of deciding which patients must be seen urgently and which can wait for an appointment—an appointment that may be several weeks away.
No matter how good the care is once a patient gets to the right place, delays mean that the healthcare system isn’t working well, not for quality of care, where delays may compromise the patient’s health, and not for costs.
Even where the current routing system works well, it can be improved using advances in technology. The advent of email and other forms of electronic information and communication have changed our expectations of response time. The medical routing system should make use of these advances to build on the existing structure, speed response time, and provide better patient satisfaction.
Perhaps the best way to think about an effective rapid-response system is ‘Triage on Steroids’…or ‘Super - 911.’
A routing service should be available 24 hours a day, seven days a week, and be performed by a knowledgeable and capable medical professional. This is the gold standard of medical routing. The system should be accessible via phone, Internet, and in person. Most of the traffic should be handled by phone or electronically; for in-person routing, the staffed routing site might be near to—but separate from—an emergency room, or perhaps at a pharmacy.
The first task of a routing service is to serve as a "super-911," to identify emergencies and reassure if urgent care is not needed.
Second, if it is not an emergency, the intake specialist could determine the complexity of the response needed. Patients requiring a simple, standard response, especially preventive care such as flu shots, could be directed to a preventive care clinic (see Step I). Patients with more complex problems should be directed to their primary care provider or, where the determination can be readily made and the primary care provider is otherwise overburdened, an appropriate specialist. Finally, patients with especially complex problems might be referred to a superdoctor team (see Step III).
To accelerate the appointments for an initial evaluation, some family practices are adopting a system known as "open access," designed to facilitate routing and expedite care. In an open access setting, no appointments (or only a limited number) are made significantly in advance. Instead, patients call into the office when they require care and are given an appointment that same day. This system provides an opportunity for a very rapid initial evaluation, allowing for routing decisions to be made literally hours after symptoms manifest.
There is another difficulty that could be addressed with creative use of new technology. Often, the best person to determine whether a particular specialist should be seen is the specialist himself or herself. But a patient moving from specialist to specialist to find out who should provide treatment is not a good strategy. It is inefficient and potentially costly in health consequences.
One approach to solving this problem is to use information routing rather than patient routing. The key is information-gathering and communication. Most of what happens at an initial medical visit to a clinic or primary care physician is a gathering of key information that will serve to determine which specialist should be seen. In information routing, after the initial visit, the information, not the patient, would be forwarded to a number of specialists.
The specialists could rapidly evaluate whether, based upon this limited information, they should be seeing the patient. Or, a specialist might provide a question--if the patient has such and so a symptom or such and so a test result, then they should be seeing the patient, e.g., “If the patient’s ears hurt while the other symptoms occur, she should see me. If not, I’m not the right specialist for this case.”
This information-based routing system, on the specialist level, serves patients better, and costs less, than patients being sent around to several specialist appointments in order to route them correctly.
An "everywhere and always-on" routing system could be made available instead of the more usual answering services, by primary care providers, provider systems or insurers. Such a system would relieve emergency rooms of having to perform the routing of non-urgent cases, freeing them to focus on the urgent and emergency care they are supposed to be providing. This type of routing system would also relieve some of the burden of PCPs, and shorten patients' wait times for routing and treatment significantly.
It is clear that in all medical settings, an accessible and reliable 24/7 accelerated triage mechanism—staffed by intake specialists and augmented by an information-transfer system—will dramatically improve our medical system’s cost-efficiency and ability to serve patients well. Wait time for care will be dramatically reduced, emergency rooms will be put to their proper use, and the burden on primary care providers will be lightened. Augmenting and improving our existing routing system is crucial to improving healthcare quality for all.
For Further Reading:
1. Merritt Hawkins & Associates, 2009 survey of physician appointment wait times. (2009).
2. K. Grumbach, D. Keane, A. Bindman, Primary care and public emergency department overcrowding. American Journal of Public Health, 83, 372-378 (1993).
3. J. R. Richards, M. L. Navarro, R. W. Derlet, Survey of directors of emergency departments in California on overcrowding. Western Journal of Medicine, 172, 385–388 (2000).
4. K. Grumbach, J. V. Selby, C. Damberg, A. B. Bindman, C. Quesenberry, A. Truman, C. Uratsu, Resolving the gatekeeper conundrum: what patients value in primary care and referrals to specialists. Journal of the American Medical Association, 282, 261-266 (1999).
5. T. Bodenheimer, B. Lo, L. Casalino, Primary care physicians should be coordinators, not gatekeepers. Journal of the American Medican Association, 281, 2045-2049 (1999).
6. C.B. Forrest, Primary care gatekeeping and referrals: effective filter or failed experiment? BMJ 326, 692-695 (2003).
7. V. Lattimer, S. George, F. Thompson, E. Thomas, M. Mullee, J. Turnbull, H. Smith, M. Moore, H. Bond, A. Glasper, Safety and effectiveness of nurse telephone consultation in out of hours primary care: randomised controlled trial. British Medical Journal, 317, 1054-1059 (1998).
8. S. R. Poole, B. D. Schmitt, T. Carruth, A. Peterson-Smith, M. Slusarski, After-hours telephone coverage: the application of an area-wide telephone triage and advice system for pediatric practices. Pediatrics 92, 670-679 (1993).
9. R. Leibowitz, S. Day, D. Dunt, A systematic review of the effect of different models of after-hours primary medical care services on clinical outcome, medical workload, and patient and GP satisfaction. Family Practice, 20, 311-317 (2003).
10. C. Arnst, A new practice: the doctor will see you today. Kaiser Health News (7/14/2010).
11. M. Murray, C. Tantau, Redefining open access to primary care. Managed Care Quarterly, 7, 45-55 (1999).
12. C. A. Moyer, D. T. Stern, K. S. Dobias, D. T. Cox, S. J. Katz, Bridging the electronic divide: patient and provider perspectives on e-mail communication in primary care. American Journal of Managed Care, 8, 427- 433 (2002).
13. S. Gatley, A. Grace, V. Lopes, E-referral and e-triage as mechanisms for enhancing and monitoring patient care across the primary-secondary provider interface.
14. Journal of Telemedicine and Telecare, 9, 350-353 (2003).
Writing and Editing Credits
Yaneer Bar-Yam with Helen P. Harte, Shlomiya Bar-Yam, Karla Z. Bertrand, and Nancy Cohen
Page 1: Checkup by Tiare Scott
Page 2: "Waiting Room 1" by Keith Syvinski
Page 3: "TeleHealth" © iStockphoto / Dale Hogan
Page 4: "Same Day Service" by Alexander S. Gard-Murray
Page 5: Routing Diagram by Alexander S. Gard-Murray and Yaneer Bar-Yam
Alexander S. Gard-Murray