Telephone Triage & Telehealth

A Brief History

An internet search of the term “telehealth” illustrates how a new industry commingles and conflates terminology, both clinical and technological. Search results include definitions of telemedicine, telephone triage, telehealth, nurse triage, phone triage, virtual visits and televisits and other forms of high-tech remote but clinical encounters between patient and clinicians.

The term Telehealth has come to stand for both the industry-at-large, as well as telephone triage — an earlier form of remote, virtual care — as a substitute for an on-site visit. Even before the pandemic, telehealth already had many facets and subsets –including home telemonitoring and management of chronically ill patient groups.

When the COVID epidemic hit, overnight, face to face visits risked contagion for patient and clinician alike. The growth of this new subspecialty was explosive and remote encounters became essential care.

However, the telehealth industry still needs evidence based research on safe outcomes. Some experts believe that both telephone triage and telehealth may be at increased risk for system error (Wachter, 2017). The remote nature of the work, subspecialty underdevelopment, incomplete systems and inadequate, poorly designed computerized decision support software (CDSS).

Telephone triage is described as a form of symptom risk assessment and triage by phone by clinicians. Essentially, it involves making decisions under conditions or uncertainty and urgency (Patel, 1995). Face-to-face triage can be challenging, and remote clinical decision-making (when one cannot see the patient or even by televisit) is more difficult. Clinicians must gather adequate, relevant information in order to estimate symptom urgency.

Telephone triage predates telehealth by 50+ years. Still an informal subspecialty, and clinicians perform this task Informally and formally, in ambulatory care settings ranging from physician offices, clinics, student health centers, disease management and ambulatory surgery, to Urgent Care, emergency department (ED) and Labor and Delivery settings, Telephone triage is ubiquitous.

Soon, the broad, high-tech field and industry of telehealth (video visits, biotelemetry, patient wearables) will subsume telephone triage – a technologically limited field based on outdated technology.

Both telehealth and telephone triage are remote encounters; however they differ in several ways. Telehealth is typically a pre-scheduled remote encounter about a non-urgent matter– a substitute for a face-to-face, routine medical appointment, and may be 20-30 minutes in length.

On the other hand, telephone triage calls are typically about acute, time-sensitive symptoms. Calls are brief (2-10 minutes), unscheduled, initiated by patients seeking clinicians’ help to decide how serious the symptoms sound. They need instructions on where, when and why they need to be seen - in the ED, Urgent care, Office or simply apply Home Treatment.

The next generation of telephone triage will require a wide range of high-tech features (video, biotelemetry, Predictive analytics, AI and patient wearables). Technology will enhance these remote, brief but urgent encounters — teletriage. Advanced technology will transform remote encounters into data driven virtual visits.

Currently, telephone triage rightfully qualifies as a form of “pre-hospital care“ — remote care with unique challenges. As an emerging nursing subspecialty and initial entry point into the continuum of care, telephone triage requires “guard rails” — a system. Traditionally, a system is composed of structure and process. Typically, systems have standard components - clinical training, standards, qualified, experienced staff, documentation and Guidelines — EMR and CDSS.

Software developers can take steps to reduce "patterns of recurrent mistakes" (Gawande) by developing and incorporating a system to avoid common error. The foundation of such decision-support systems is based on the Duty of Due Care. The Duty of Due care requires clinicians and employers to “do what a reasonable, prudent clinician or employer would do under the same or similar conditions”.

Guard rails — like professional standards, ethical practices, and traditional medical practices -- form the basis for legal decisions. A system — structure and process — enhance safety and reduce recurrent error. One example is that of “Rules of Thumb” that augment decision-making under conditions of uncertainty and urgency in both remote triage as well as face to face triage

Rules of Thumb for Triage Clinical Decisionmaking

Research in clinical decision-making has identified heuristics (rules of thumb) as shortcuts. Rules of Thumb used for clinical decisionmaking for triage may apply to remote triage as well as face-to-face triage.

·       When in doubt, always err on the side of caution, and bring the patient in sooner rather than later.

·       “When in doubt, send ‘em out”.  (Clawson, 1998).

·       Always speak directly with patients; A patient “too sick to talk” is a “Red Flag” and should be evaluated on site

·       Beware of the middle-of-the-night call

·       Beware the “Recent or Previous Diagnosis”

·       Remain alert for atypical, silent or novel presentations.

·       Beware of “failure to improve” on current Rx or Home Treatment.

·       “Never abandon the caller in crisis” (Clawson, 1998).                                          

·       The vaguer the symptoms, the greater need for good data collection.

·       Speed does not equal competence; avoid premature closure or jumping to conclusions.

·       Beware the “Non-Diagnostic Diagnosis” (patient interpretation of symptoms)

·       Beware the “Out of Protocol” experience.

·       Two or more calls within hours or days should be seen urgently (1-4 hours)

·       Patients described as “too sick to talk on the phone” may require an urgent appointment

·       All severe symptoms must be seen in 1-8 hours or less.

Age-Based Rules of Thumb

·       Assess all sick children and  elderly for possible dehydration and sepsis

·       All new or worsening confusion in children or elderly is considered emergent.

·       Elderly and pediatric patients may present in silent, atypical or novel ways

·       Elderly and pediatric populations are at greater the risk of hypo- or hyperthermia during weather extremes.  

·       All Teens (including College Student/Young Adult)  are at increased risk for suicide/violence when stressed or depressed due to impulsivity

·       Elderly are at higher risk for completed suicide, especially males over 65 years. who are white, widowed, retired and unemployed.

Trauma-Based Rules of Thumb

·       Trauma + Suspicious History: Consider Possible Domestic Abuse

·       Always consider head and neck injury when there is face or jaw trauma

·       All snakes are considered poisonous until proven otherwise.

·       All chemical and electrical burns have the potential for progressive injury

·       Never remove impaled objects.

Symptom-Based Rules of Thumb

·       All severe pain must be seen within 8 hours or less.

·       Beware of any pain that awakens patient or prevents sleep at night

·       Headaches described as: “First, Worst, Burst, Cursed (other accompanying symptoms), or 51st (age over 50 years)” = Emergent

·       “Temperature extremes often trigger medical problems”. (Clawson, 1998)

·        “Epigastric pain in males > 35 and females > 45, is considered an MI until proven otherwise”.  (Clawson, 1998).

·       Any pain between the navel and nose is chest pain until proven otherwise

·       The first symptom of an MI may be denial.

·       Once an ectopic, always an ectopic

·       Any bleeding in pregnancy is an ectopic until proven otherwise

·       All first-time seizures must be evaluated .

·       All rashes are contagious until proven otherwise

·       Beware of any atypical, silent or novel presentations.

·       Beware all  “flu” symptoms that can “mask” MI, Infection  or sepsis.

·       Pregnancy and breast feeding may be risk factors for domestic violence

  • All High-Risk Patients with moderate symptoms of any kind may require higher triage acuity.

Rule of Thumb for Myocardial Infarct Risks: “The Eight E’s”

Extremes of:

  • Emotion

  • Extremes of Weather/Temperature

  • Exertion

  • Extreme Age:  >75

  • Eating (“Holiday Heart” ?)

  • Epigastric Distress

  • Essential Hypertension

  • Early AM

© Sheila Quilter Wheeler, 2025

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 14.  van Leeuwen YD, Mol SSL, Pollemans MC, Drop MJ, Grol R, van der Vleuten CP. Change in knowledge of general practitioners during their professional careers. Fam Pract 1995; 12: 313–317.

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