A Workflow to Improve Completed Telephone Triage with Patients Reporting Symptoms through Patient Portal Messages

Introduction: There has been rapid growth in the number of patients utilizing their patient portal to communicate with their healthcare providers since COVID. Despite guidance explicitly instructing people not to send messages related to urgent concerns, triage is still required of many client requests.
Background: Since November 2022, the primary care Epic MyChart messages of a midsized urban safety net health system (29% non-white; 63% primary language non-English) related to non-urgent medical questions and scheduling requests including report of symptoms have been routed to a centralized nurse triage department (NTD), averaging approximately 5500 messages monthly.
Problem addressed: Standard of care had been initiation of telephonic responses to messages warranting triage. A quality review of 200 calls over two weeks in June 2024 concluded that only 21% of initial calls resulted in message completion, and initial responses typically started at 48-business hours post-message receipt.
Methods: A project team including risk management and nursing and operations leadership was assembled. A literature search revealed no applicable studies have been conducted. A question posed on the AAACN telehealth community suggested other institutional workflows were consistent with ours.
Intervention: A standard message response was developed and approved in multiple languages, advising patients to call the NTD for further assistance. Nurses were instructed to scan messages for urgent or emergent concerns and respond with the standardized message if appropriate. Additionally, workflows were developed incorporating the primary care central scheduling team (CST). A “red flag” policy to guide non-clinical personnel on rapid identification of medical emergencies reported by offsite clients was updated to support CST screening of MyChart scheduling requests, including reported symptoms. The CST received 1:1 training on a new workflow entailing phone outreach and warm handoff to the NTD emergency line if a red flag symptom was reported or replying with the standard smart phrase in the patient’s preferred language.
Findings: Pilot of the updated workflows started in September 2024. Post-implementation quality review of 200 MyChart messages routed to the NTD on two dates in October 2024 showed 85% and 86% of patients following through with in reach after receiving the standardized message response. No “red flag” symptoms were reported among these messages. Time to initial message response decreased to 10 business hours on average. No relevant safety events have been reported.
Conclusion: Piloting a workflow for symptom-reporting patient portal messages that instructs patients on in reach to nurse triage has thus far resulted in a decrease in response times and an increase in nursing efficiency without compromising patient safety or quality of care in a diverse, safety net primary care patient population.