Digital Foundations of the Triage Process in Swiss Primary Care Practices

A BFH study assessed the current digital situation in five primary care practices in German-speaking Switzerland: documentation and billing are handled electronically, whereas initial contact is usually made by telephone. From this, a triage process was developed that guides patients directly to the appropriate professional and harnesses the potential of Advanced Practice Nurses (APN) and medical practice coordinators (MPK).

Introduction

Owing to demographic change, the number of people with chronic and multiple conditions who require primary care is rising [1–4]. At the same time, scientific and technological advances enable faster detection of health problems as well as new channels of communication. Nevertheless, digitalisation in Swiss primary care is still at an early stage of development and raises questions concerning data security, efficiency, financing, and ethics [5].

In Swiss primary care practices, professionals such as Advanced Practice Nurses (APN) and medical practice coordinators (MPK) are increasingly taking on new tasks [1, 6]. For patients to benefit from these interprofessional care models, the current triage process must be adapted. At present, patients are assigned primarily to physicians regardless of their concern [4, 6], even though evidence-based guidelines for chronic conditions recommend collaboration in interprofessional teams [7–9]. This underscores the need for an adapted triage process.

Method

To this end, a study using a variety of methods was conducted. The guiding research question was: How should the patient triage process be designed so that, in new care models involving MPK and APN, patients reach the appropriate professional who can respond optimally to their individual needs?

Five primary care practices in German-speaking cantons, in which APN and MPK were already working, took part. Participation was voluntary, and participants could withdraw from the study at any time. As no health data were collected, approval of the local ethics committees was not required [10].

Data collection and analysis

Among other methods, the triage process was observed over a total of 10 days and documented in detail. A literature-based data collection instrument was developed for this purpose.

These data were then analysed using descriptive statistics where possible. The textual data were examined by means of content analysis [11]. On this basis, relevant information on digital transformation was extracted, and a triage process was developed.

Results

The participating practices were located in rural (3 practices) and urban (2 practices) areas, with around N=26 staff (of whom 23 were women, 88.46%; 5 physicians, 5 APN, 2 MPK, 14 MPA). In total, N=113 patient contacts were recorded (69 women, 61.06%; sex not documented for 1). On average, patients were 53.04 years old (SD: 20.77; range: 7–87 years; year of birth not documented for 3). Almost all patients (n=103, 91%) were known to the primary care practices.

Table 1: Observed patient contacts (N=113)

All N=5 primary care practices used an electronic system for managing patient data, billing, and referrals. The telephone served primarily for scheduling appointments, patient intake, and internal and external communication. In one practice, telephone calls were systematically recorded and stored locally.

In two practices, e-mail was used to respond to patient enquiries, for example for prescription renewals. Two practices also enabled online appointment booking via an electronic calendar. For internal information exchange, handwritten notes were used in n=3 practices, while n=1 practice used a digital team chat. To support assignments, one practice used the recommendations of Schaufelberger et al. [12] together with a supplementary list it had compiled.

Table 2: Assignment of the N=113 patient contacts

Based on this information, a modified triage process was developed. In this triage process, assignment to the various professionals is proposed on the basis of possible diagnoses and the urgency of the complaints.

Table 3: Modified triage process within primary care practices

Legend: MPA = medical practice assistants, MPK = medical practice coordinators, APN = Advanced Practice Nurse. In Swiss primary care practices, MPA or similar professionals usually carry out the assignment to the other professionals. To do so, they ask questions about the current problem and its urgency.

Discussion

This study examined patient triage in primary care practices with APN and MPK and, from this, developed a modified triage process. The participating practices were located in German-speaking Switzerland; an APN worked in all of them, and two additionally employed an MPK. Both professional groups are so far still not widely established in Swiss primary care practices [4, 13, 14].

The results show that patients continue to be assigned predominantly to physicians. Direct assignments to APN were possible only in isolated cases. Reasons for this include, among others, the legal framework as well as uncertainties regarding the competencies and areas of responsibility of APN. Standardised job descriptions could facilitate delegation and create greater transparency [3, 15].

Although all practices use digital systems for documentation and billing, many workflows are still carried out in analogue form. A digital implementation of the developed triage process will require further technical and organisational development [5, 16].

Owing to the small sample, the study’s explanatory power is limited. However, the developed triage process was rated positively by the professionals involved and could improve access to primary care. Further research on transferability, on the role of APN, and on the digitalisation of the process is needed [3, 16].

Conclusions and recommendations

The present study examined the triage process in primary care practices with APN in German-speaking Switzerland and, from this, developed a modified analogue triage process. Its digital implementation requires further research. Introducing this triage process appears fundamentally feasible, particularly in light of the legal framework for delegation. Here, the standardised job description for APN in Swiss primary care practices can offer important guidance [3].

Acknowledgement

Without the dedicated support of the colleagues on the project and the contributions of the participants, this project would not have come about.

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