Telephone triage, expert systems and clinical expertise

Abstract

This paper reports on a qualitative study of the use of an expert system developed for the British telephone triage service NHS Direct. This system, known as CAS, is designed to standardise and control the interaction between NHS Direct nurses and callers. The paper shows, however, that in practice the nurses use CAS in a range of ways and, in so doing, privilege their own expertise and deliver an individualised service. The paper concludes by arguing that NHS Direct management's policy of using CAS as a means of standardising service delivery will achieve only limited success due not only to the professional ideology of nursing but also to the fact that rule-based expert systems capture only part of what 'experts' do.

The work, workforce, technology and organisational implications of the ‘111’ single point of access telephone number for urgent (non-emergency) care: a mixed-methods case study

“…This merging of lay expertise (call advisers) and professional expertise (clinical advisers) with the CDSS expertise is reflected in the wider literature. For example, our findings are similar to those of Greatbatch et al 44 who found that nurses used a CDSS in a range of ways, incorporating and valuing their own expertise, to 'deliver an individualised service' (p. 802). Berg 45 suggests that it is often necessary to adapt the formal rules (algorithms) of CDSS to accommodate the complex, multifaceted issues that arise in clinical decision-making, reflected in the literature about nurses using CDSS.…”

“…Berg 45 suggests that it is often necessary to adapt the formal rules (algorithms) of CDSS to accommodate the complex, multifaceted issues that arise in clinical decision-making, reflected in the literature about nurses using CDSS. 44,46 Flexible, non-standardised use of the system is a means of mediating the (real or perceived) 'oversensitivity' of the CDSS (or 'risk averseness' as sometimes described by staff). Previous research suggests that the CDSS is often oversensitive (it does not miss sick patients and therefore it is safe) but that it tends to 'over-triage' (it identifies 'too many' false positives because it is not specific enough).…”

Care at a Distance : On the Closeness of Technology

“…9. Miller 2006Greatbatch et al 2005;Smith & Godfrey 2002;Tuckett 2002. 10. In the horror image of the abandoned, technologically mediated patient, nobody is looking after the patient.…”

Effects of computerized decision support systems on nursing performance and patient outcomes: a systematic review

“…If adherence is greater in one arm of the trial, reasons for this can then be explored; collection of qualitative data could be useful for this, as demonstrated by qualitative studies of CDSS use in first contact care. 28,29 As discussed above, contamination is a significant issue facing RCTs in this area as inadvertent application of the intervention, or aspects of the intervention, to the control group can dilute the effects of the intervention. Therefore, randomisation should be at the practitioner or unit level.…”