THE BRAVE NEW WORLD OF Enhanced Pattern Recognition

AI-AUGMENTED TELEPHONE TRIAGE

The work of teletriage is nothing if not uncertain, and humans intensely dislike uncertainty.  However, it is reasonable and prudent to acknowledge the limitations of this work, and to question our assumptions about it.  Safer practice and evidence-based tools can reduce uncertainty and improve outcomes.

“Triage (on site) is not an endpoint but a beginning.” American College of Emergency Physicians, 1999. Uniform Triage Scale in Emergency Medicine, Information Paper

"Physician expertise and professionalism alone could not prevent common error.” Killip. (2007),

“All learned occupations have a definition of professionalism, a code of conduct.  It is where they spell out their ideals and duties.  They all have at least three common elements:  expectation of selflessness; of skill; and of trustworthiness.  Aviators have a fourth expectation -- discipline”.  (Gawande, 2010)   

‘We don’t look for patterns of our recurrent mistakes or devise and refine potential solutions for them. But we could, and that is the ultimate point”(Gawande, 2010).

“Any mistake or failure in the diagnostic process can lead to a diagnosis that is wrong, missed or delayed. More diagnostic errors occur in ambulatory settings, but inpatient diagnostic errors tend to be more lethal”. Groszkruger, 2014.

AI Safety

CDSS that employs AI without a governing framework and guard rails - might produce unsafe outcomes.

Errors of Assessment, Communication, Continuity, Informed Consent and Human Error. (Joint Commission) are Root Causes of unsafe outcomes in teletriage. Malpractice cases in teletriage are typically related to these predictable and preventable errors. Human and system error can be addressed by improving systems —structure and process — a group of related parts that work together for common goals — patient safety, practitioner safety, system effectiveness.

Meets Manchester Triage
Group Triage Requirements

1.     Practice Management:

a.    Clinical Training - Five CE courses

b.    Risk Management

c.     Clinical Standards:  Practice & Call Center

d.     Pending: Universal Guideline - EBM certified & AI/PA enabled

2.     Clinical Trends/Health care Technology: CDSS, EMR

3.     Financial Performance:  Tracking and Trending Capabilities

4.     Patient Experience:

a.    Patient Brochure on how to use Advice Nurse Service

b.    Patient Educational Material for Symptom-Based Calls 

 Meets Developer Standards for POC AI-CCDSS

  1. AI/PA-Ready

  2. A Single, Robust Template streamlines development

  3. Adaptable to All Ages

  4. Rapid integration, updating, modifying & testing

  5. Multi-Purpose, Multi-Setting

Patent Pending 2024-2025

Evolution of A Universal Guideline to AI-Ready CDSS

1993 Master Template format to develop a set of Guidelines with minimal disposition details, three acuity levels

1995 Contingency Protocol, NPF = No Protocol Found (when no Protocol seems to apply) A “Fall-Back” Protocol for the “Out of Protocol Experience” with Dispositions 5 level acuity-described and defie categories, time and place for further evaluation

1998 Pre-Emptive Protocol. The Go-To Protocol for the first pass prior to selecting a specific guideline

2000 Master or Generic Guideline Developed Framework Protocol and Template

2002  Universal Guideline More robust with broad Key Questions to rule out common emergent to non-acute symptoms,

2002 Universal Guideline as Training adjunct to introduce broad principles and policies, for new staff

2002  Universal Guideline for Face-to-face triage in ambulatory settings: on-site — ED and Urgent Care, any ambulatory or pre-hospital setting: Office, Clinic, College Student Health.

2020-2025 Universal Guideline Standalone Proof of Concept- semi -working, with Reminders, QA questions, Built-Nursing Process, Error Feedback, Ready for EBM testing — As-Is or AI-ready.

A Universal Guideline

A Robust Template for a Clinical Decision Support System Some telephone triage CDSS are confusing, complicated and unsystematic. Many telephone triage protocols and CDSS designs are unwieldy for research purposes — making it difficult to demonstrate that a given CDSS qualifies as evidence-based medicine (EBM). In general, inadequately tested CDSS may actually interfere with the decision making process (Wachter, 2017).

A Universal Guideline Online: Fast & Cost-Effective to Test & Update

Telephone Triage Protocols and CDSS designs must be proven valid and reliable. Nurses need user-friendly tools— elegant, transparent and seamless. Standards or guard rails are essential for the next generation of AI-assisted CDSS. Meaningful research on how to safely incorporate AI/PA into current CDSS is urgently needed.

All-Purpose CDSS: Telephone Triage, Telehealth or ED Triage
Generative AI, predictive analytics, advanced EMRs and biotechnology will be standard components of CDSS in the near future. These powerful technologies, require a reliable system within which to operate — guardrails.

Typically, acknowledged clinical subspecialties require systems: clinical training, clinical practice standards, safe CDSS, EMR and experienced decision makers trained in clinical decision making. In other words, clinical systems must meet the Duty of Due Care — a legal principle underlying established subspecialties.

A Universal Guideline with embedded standardized components — structure and process — serves as a virtual office visit — abbreviated History and Physical Relevant past and recent patient medical history or “back story” (the EMR) - provide contextual information about the patient’s risk level. Essential assessment questions elicit more information about the chief complaint.

Early on, protocols were thought of as having a physician at one’s side while making difficult clinical decisions— supporting, reminding and prompting with additional questions. AI and predictive analytics supplant the expert physician advisor, synthesizing, supporting pattern recognition and suggesting an acuity level and triage disposition.

“Improved Systems improve safety” Giesen et al., (2011), Annals of Medicine

“If you fail to plan; plan to fail” (IOM)

Does your organization have a formal system? Or is it just “bits and pieces”? The Institute of Medicine defines system error as “failure to use a plan; using the wrong plan; or failure of planned action to be completed as intended”. Institute of Medicine, 2000. [PubMed]

CERNO…..I Perceive - -
Discern – Distinguish – Sift – Separate - Bear in Mind – Reckon – Determine – Resolve – Contend - Decide