TeleTriage Systems: Advancing Telephone Triage for Safer, Smarter Healthcare
Company Overview
TeleTriage Systems is a consulting company specializing in the development of telephone triage systems—also known as pre-hospital triage—performed by registered nurses. The company mission is to improve the safety, efficiency, and timeliness of this critical service. When patients call, concerned by worrisome symptoms, nurses assess the symptoms and decide when, where, why, and whether patients might require further clinical evaluation on site — in the ED, Urgent Care, Office or Clinic.
Nurses use Clinical Decision Support Systems (CDSS) alongside Electronic Medical Records (EMR) to assess, document, estimate symptom acuity, and to advise disposition decisions. While it is widely believed that telephone triage can reduce emergency department (ED) overcrowding and improve cost-effectiveness, there is limited peer-reviewed research to substantiate these claims.
Leadership
TeleTriage Systems was founded by Sheila Quilter Wheeler, RN, MSN, a pioneer in pre-hospital telephone triage. Ms. Wheeler’s career spans over four decades and includes the development of nurse-driven triage systems, CDSS tools, clinical training programs, and national conferences. Her clients include government institutions such as the Hospital Authority of Hong Kong, military medical facilities, HMOs, private practices, and community clinics.
Ms. Wheeler authored the first training manual for telephone triage and led a task force of 23 expert-level nurses, nurse practitioners and three physicians in developing the first age-specific, five-level pre-hospital triage guidelines. These guidelines are grounded in research on ED nurses’ reliance on pattern recognition and context-based decision-making (Patel & Lephrohon, 1995), applying a heuristic approach to clinical decision-making.
Evolution of the Field
Telephone triage predates telehealth, which surged during the COVID-19 pandemic to limit viral exposure for patient and clinician alike. Today, telehealth—defined as real-time virtual consultations between patients and clinicians—has become a convenient alternative to in-person visits. Over time, telehealth will likely replace traditional telephone triage, especially as wearable technologies and biotech tools continue to evolve.
In the post-COVID landscape, virtual visits now serve not only for convenience but may also serve as pre-hospital triage virtual encounters. However, telephone triage remains distinct in that in telephone encounters clinicans cannot see patients. and decision making relies heavily on nurses’ clinical reasoning and judgment.
Current Challenges
The field of telephone triage faces a “perfect storm” of urgent issues:
Inadequate regulation and standards for a still-emerging clinical subspecialty
Patient safe, timely access vs. reducing system costs
ED overcrowding due to inadequate pre-hospital triage structure and processes
Insufficient patient access after-hours to alternate sites other than the ED, often due to outdated policies
Despite the ubiquity of triage calls to ambulatory settings, clinics, EDs, and call centers since the 1980s, the field has grown unevenly. The rapid advancement of IT has outpaced professional standards and regulatory oversight.
Moreover, many CDSS tools are designed by physician/IT teams without substantive, meaningful input from nurses—who are the primary users—and without rigorous outcome studies. It's unclear if these tools are used as intended or if nurses’ high safety outcomes are driven more by clinical caution than tool effectiveness.
Looking Ahead: Integrating AI Thoughtfully
Artificial intelligence is poised to transform decision support tools. However, many existing CDSS platforms are not yet AI-ready. Overly complex designs, lack of a clear clinical process and pathways, and an overwhelming number of disposition options make these systems difficult to maintain, revise, or scale. Without thoughtful design, these tools risk becoming obsolete and unsustainable.
TeleTriage System’s Solution: A Return to Clinical Foundations
TeleTriage Systems draws on foundational work from healthcare quality and safety leaders, including Atul Gawande, MD; Avedis Donabedian, MD; Barbara Siebelt, RN, MS; and Laura Mahlmeister, RN, PhD. Ms. Wheeler has synthesized decades of research and standards from top agencies and specialty organizations such as the IOM, Joint Commission, NCQA, MTG, ACEP, ENA, and AAACN.
The company’s core approach is guided by:
The Duty of Due Care
The Nursing Process
Clinical pattern recognition and context
Evidence-based clinical guidelines
Safe, Timely Patient Outcomes
From this foundation, TeleTriage Systems has developed a prospective Universal Guideline, a single, robust CDSS template—essentially an “Uber Triage Checklist.” In her role as a consultant and expert witness in over 35 malpractice cases, Ms. Wheeler has identified recurring error, both human and system related. These insights directly inform the design of safer, more reliable tools.
Vision
With proper validation through evidence-based medicine (EBM), TeleTriage System’s prospective cloud-based AI-integrated CDSS-EMR could set a new industry standard—improving patient safety, enhancing care quality, reducing resource use, and even contributing to a lower carbon footprint.
This material was lightly revised with the assistance of ChatGPT, a language model developed by OpenAI.
Are We Asking the Right Question?
Is the question: What is the cause of these symptoms? or How urgent are these symptoms?”
EXPERTS HAVE WEIGHED IN
“Telephone triage represents a grey area between medicine and nursing where medical diagnoses are not essential in order to make a decision about the appropriate interventions, where the dimension of urgency becomes the primary focus of the reasoning process.” Lephrohon & Patel, J. Med Decisionmaking, 1995
”Triage (remote and face to face) is not an endpoint but a beginning”. Systems with a basic premise of attempting to make a tentative medical diagnosis at triage are doomed to fail.
.....triage, by definition, has limited time, history, and objective data. The only appropriate focus of triage is to identify key signs/symptoms so as to place patients in an appropriate level for their generic acuity or risk.” Manchester Triage Group in Zimmerman, 2001
System Error: If you fail to plan; plan to fail”
The Institute of Medicine defines medical (or system) error as the failure of a planned action to be completed as intended, or use of a wrong plan, or failure to use any plan. When negligence (as in a malpractice case) is alleged, the system will be used as evidence. Expert witnesses will request and examine the system components.
A Brief History of TeleTriage Systems
Founded in 1985 by Sheila Quilter Wheeler, RN, MS., TeleTriage Systems was among the first clinical consulting firms to the telehealth industry. Wheeler began pioneering the field — developing and teaching “The Fine Art of Telephone Triage” — a basic on-site clinical course.
In quick succession, Wheeler established a track record of innovation. Wheeler and Judith Windt, medical writer, authored the first training manual for Telephone Triage, published in 1993 by Delmar Thomson.
In 1994, Wheeler collaborated with Contemporary Forums to develop the first clinical telehealth conference for nurses. In 1995, Wheeler launched teletriage.com, one of the first telehealth websites. Google quickly ranked it as a website of quality in the top 10-20 of similar websites. Teletriage.com served as a clearinghouse of telephone triage information in the early days of the field.
In 1995, Wheeler consulted for Santa Clara Medical Center, a Medical Center serving a high-risk, low-literacy, multi cultural patient population of 1.2 million. Wheeler spearheaded a project to train nurses and develop telephone triage guidelines for this challenging population. She served as Editor-in-Chief to collaboratively lead a team of 23 expert nurses, nurse practitioners and physicians to develop the first 5-level triage, age-specific telephone triage guidelines.
From 1997 - 2020, Wheeler served as a Clinical Informaticist, collaboratively developing electronic software with LVM Systems for six VA hospitals in northern California and Hawaii. She consulted and presented seminars for a range of clients, from military facilities to international institutions. Wheeler developed a Telephone Triage course for physicians at Keck School of Medicine in Los Angeles, California.
For over 40 years, Wheeler has consistently worked to develop products that are “real world” — practical, user-friendly, transparent and as evidence-based as possible — built by experienced clinicians who practice telephone triage.
Inspired by the work of Atul Gawande, MD and informed by her experience as a legal nurse consultant on telephone triage malpractice cases, Wheeler’s mission has been to develop system components that reduce common teletriage errors.
Teletriage.com, a pioneering teletriage website — 1998 - 2023
Please come BROWSE TELETRIAGE.COM on the INTERNET ARCHIVE
Telehealth: An Evolving & Emerging Subspecialty
TELETRIAGE DERIVES DECISIONMAKING & PROFESSIONAL STANDARDS FROM TRIAGE
“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; & of trustworthiness. Aviators have a fourth expectation -- discipline”. (Gawande, 2010)
Human Error
In the ValuJet plane crash, “mechanics employed a “good old-fashioned pencil whipping”, resulting in the ValuJet plane crash. These “blizzards of small judgments” amount to a “widespread form of the ‘normalization of deviance’”. Langwiesche laments the failure of large systems that create an “entire pretend reality” that includes:
Unworkable chains of command
Unlearnable training programs
· Unlearnable training program
· Unreadable manuals
· a fiction of regulations, check and controls.
Langeweische (1978)
Face-to-Face Triage Standards Inform Remote Triage Standards
Emergency department triage: an ethical analysis
Triage is part of the healthcare continuum, which consists of a range of services — pre-hospital care [19], and onsite care. Teletriage is a form of pre-hospital care, when performed by clinicians. The levels described below apply to remote triage as well:
1. First, pre-hospital or remote triage to determine if ambulance and/or pre-hospital care resources are required.
2. Second, if symptoms are not emergent, remote triage by the first clinician attending the patient.
3. Third, triage on-site at the hospital ED.
Remote Triage conceivably meets the first two criteria. It is the first point of contact for patients seeking clinical advice about their symptoms.
The Duty of Due Care requires developing a plan, based on set of criteria to determine a treatment priority for each patient. It is safe to assume that telephone triage — remote, pre-hospital care — also requires a system.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3199257/ VBMC (2011) doi: 10.1186/1471-227X-11-16 PMID: 21982119
Access to Care, Delay in Care, Timely Care in Triage & Teletriage
“Standards for access to care are hotly debated for scheduled surgical procedures using delays of days, weeks, and months to determine what is acceptable or reasonable. No such time objectives exist in Emergency Departments (or for telephone triage) where delays of minutes or hours for unrecognized problems can be the difference between life and death. Without using a standard measure such as a national triage scale it will be difficult to measure acuity, perform case mix comparisons, or develop ED operational standards.” Adapted from American College of Emergency Physicians (1999)
https://www.acep.org/siteassets/uploads/uploaded-files/acep/clinical-and-practice-management/resources/administration/triagescaleip.pdf
Building Safer Tele-triage Systems — One Component at a Time
Mission - Vision - Standards
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![Patient Safety in Tele-triage]()
Mission
Patient Safety — Safe Practice — Safe Products
To devise and refine potential Solutions and Systems to reduce patterns of recurrent mistakes in tele-triage.
Develop evidence-based Structure and Process to enhance the safety and effectiveness of remote clinical tele-triage encounters
Improved Decisions and Patient Outcomes in Tele-triage.
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![Teletriage vision]()
Vision
An established professional clinical telehealth subspecialty
Complete, high Quality, Integrated System Components
Safe, Reproducible, Evidence-based Outcomes
User friendly Decision Support Tools
Substantive Clinical Teletriage Training
Decision Support Teletriage Systems supported by Artificial Intelligence and Evidence-based Research
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![Standards teletriage protocols]()
Standards
Wheeler’s products are guided by time-honored traditions of safe medical practice and clinical decision making derived from the tools of Patient History and Physical.
Wheeler relies on current recognized standards for Safety: National Academy of Medicine (NAM), Institute of Medicine (IOM) Joint Commission, American College of Emergency Physicians (ACEP), American Association of Ambulatory Care Nurses (AAACN), Manchester Triage Group (MTG), URAQ, AHRQ
