Summer 2020 (Volume 30, Number 2)

Tracking Triage Targets for Rheumatoid Arthritis

Steven Katz, MD, FRCPC

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The University of Alberta Division of Rheumatology began its Central Triage service in 2009, with the goal of providing timely access to care for patients with inflammatory arthritis and active connective tissue disease, and equal access to care for patients referred for noninflammatory conditions. We previously published on our success, using the “gestalt” method of triage – rheumatologist’s intuition – without any additional requirements beyond what the referring letter provided.¹

In 2012, our clinic transformed from paper-based to a fully integrated electronic medical system based on Epic Systems. With this change, we took advantage of Epic’s triage module, moving from a paper-based Access database triage system to an integrated system within our electronic medical record (EMR). The risk of this move was whether or not we would be able to follow metrics, as being able to analyze the triage system in near real-time to understand where it is working or not, was as important as how the system worked. Fortunately, we were able to work with the local Epic team to develop easy to retrieve metrics around referral volume, physician volume, patient disease mix, and wait times for “soon” and “routine” referrals. This allowed us to constantly suggest subtle changes to our intake to at least try to optimize patient wait times.

Because our triage system is based on a gestalt system, it was important to develop a way to monitor “rheumatologists’ intuition” and provide feedback when potential errors were made. Specifically, we wanted to ensure we were seeing our rheumatoid arthritis (RA) patients in a timely manner, triaged with the “soon” urgency. This is what we submitted for the Practice Reflection Award this past year.

We were able to develop an algorithm where we could identify patients who were diagnosed with RA in clinic but were not assigned a “soon” urgency status in triage. We could then identify the triage physician who made this “error” and each year, provide them this list of patients to review. Each rheumatologist could then review both the initial referral and the clinic consult letter in the chart to determine if an error was made and reflect on whether or not they needed to consider changes to their future triage practice.

We have been able to provide this data for our rheumatologists for the last few years, with approximately 50-75 patients (1-2% of total referrals) identified across the group. To date, the feedback from fellow rheumatologists suggests the vast majority were in fact correctly triaged, but rather may have been second opinions or incomplete referrals which did not clearly suggest an inflammatory picture. This provides reassurance to our group that our triage system appears to be functioning as intended.

We have recently upgraded our EMR to a new Epic system, which means re-inventing the wheel so to speak. We are working with our local Epic team to re-establish these useful metrics and benchmarks so we can continue to ensure we are providing the best possible access to rheumatology care in Edmonton and Northern Alberta.

References:

1. Carpenter T, Katz SJ. Review of a rheumatology triage system: simple, accurate, and effective. Clin Rheumatol. 2014 Feb;33(2):247-52. doi: 10.1007/s10067-013-2413-1.

Steven Katz, MD, FRCPC
Associate Professor,
Department of Medicine
University of Alberta
Edmonton, Alberta