Assessing the utility of artificial intelligence throughout the triage outpatients: a prospective randomized controlled clinical study

Currently, there are still many patients who require outpatient triage assistance. ChatGPT, a natural language processing tool powered by artificial intelligence technology, is increasingly utilized in medicine. To facilitate and expedite patients’ navigation to the appropriate department, we conducted an outpatient triage evaluation of ChatGPT. For this evaluation, we posed 30 highly representative and common outpatient questions to ChatGPT and scored its responses using a panel of five experienced doctors. The consistency of manual triage and ChatGPT triage was assessed by five experienced doctors, and statistical analysis was performed using the Chi-square test. The expert ratings of ChatGPT’s answers to these 30 frequently asked questions revealed 17 responses earning very high scores (10 and 9.5 points), 7 earning high scores (9 points), and 6 receiving low scores (8 and 7 points). Additionally, we conducted a prospective cohort study in which 45 patients completed forms detailing gender, age, and symptoms. Triage was then performed by outpatient triage staff and ChatGPT. Among the 45 patients, we found a high level of agreement between manual triage and ChatGPT triage (consistency: 93.3–100%, p<0.0001). We were pleasantly surprised to observe that ChatGPT’s responses were highly professional, comprehensive, and humanized. This innovation can help patients win more treatment time, improve patient diagnosis and cure rates, and alleviate the pressure of medical staff shortage.


Introduction
Recently, the National Bureau of Statistics of China reported that there were over 8.42 billion outpatient visits in the country in 2022 (1).With such a large volume of patients seeking medical attention, effective triage becomes paramount for efficient and accurate diagnosis and treatment.Correct triage is crucial for the effective management of patients' health conditions (2,3).Traditional manual triage methods are often influenced by the experience and seniority of medical staff (4).However, intelligent triage systems, such as those based on AI, eliminate these potential biases (5).Studies have shown that smart phone triage applications can reduce the error rate in triage decisions, shorten consultation times, and help relieve the pressure on medical staff (5).Despite these advancements, the interaction mode of mobile App triage is still relatively fixed and may not provide personalized feedback to patients.In recent years, AI systems based on Chat Generation Pre-Training (ChatGPT) have gained significant attention and are increasingly being applied in healthcare settings (6).However, the application of ChatGPT in outpatient triage has not been fully explored.Therefore, this study aims to evaluate the utility of ChatGPT in outpatient triage.We hope to demonstrate the potential of ChatGPT to enhance triage accuracy, speed, and patient satisfaction, while also reducing the workload on medical staff.

Methods
This study employed a retrospective cohort study and a prospective cohort study.
Retrospective Cohort Study: In March 2023, we conducted a random sampling of 30 outpatient medical records out of the vast pool of 100,000, spanning across the departments of Internal Medicine, Surgery, Gynecology, Pediatrics, and the Emergency Department at the First Affiliated Hospital of Gannan Medical University.The symptoms (Supplementary Figure S1) of these 30 cases were representative of common clinical symptoms encountered in clinical practice (7,8).ChatGPT was used to answer 30 corresponding questions, and the responses were then scored by 5 experts.All 30 responses were independently assessed by 5 experts and given a score, which was ultimately averaged to ensure accuracy and consistency.
Prospective Cohort Study: We provided a form with age, gender, and symptoms, and randomly assigned 45 outpatients to fill out.Based on the tabular information, triage was performed both manually and using ChatGPT.The consistency of manual and ChatGPT triage was evaluated by 5 experts, and statistical analysis was performed using the Chi-square test.The manual triage personnel included professionally trained nurses and healthcare-related personnel.The assessments of the 5 experts are independent.
The 5 experts were all doctors who had worked in tertiary general hospitals for more than 5 years and held the qualification of attending physicians.They worked in departments such as respiratory medicine, hematology, oncology, pediatrics, and general surgery.They are assessed independently, first answering questions based on their own expertise and then evaluating ChatGPT's responses.The independent evaluation by experts was based on the following principles: 1. Accuracy of ChatGPT triage; 2. Clarity of language expression; 3. Degree of first aid awareness; 4. Service attitude.
This study was conducted anonymously and without compensation, and was approved by the Ethics Committee of Ruijin People's Hospital (approval No. 2023002).ChatGPT-3.5 was used in the study.

Results
The retrospective cohort study revealed that among the 30 answers reviewed by 5 experts, 17 received high scores (10 and 9.5 points), 7 received relatively high scores (9 points), and 6 received relatively low scores (8 and 7 points; Figure 1A).The 17 high-scored answers reflect comprehensive and professional analysis, hierarchical diagnosis and treatment systems, first aid concepts, and humanization.The 7 high-scored answers are generally professional and comprehensive but have room for improvement.The 6 relatively low-scored answers are relatively incomplete and unprofessional.These are shown in Figure 1A, Table 1, and Supplementary Table 1.
The prospective cohort study revealed that among these 45 outpatients, five specialists considered manual triage to be particularly consistent with ChatGPT triage.We found that 3 reviewers thought that the consistency of manual and ChatGPT triage was 100% (p<0.0001; Figure 1B), 1 reviewer thought that the consistency was 95.6% (p<0.0001; Figure 1B), and 1 reviewer thought that the consistency was 93.3% (p<0.0001; Figure 1B).
Overall, the results indicated that ChatGPT's answers provided accurate and professional triage information to patients without providing misinformation or harmful information to patients.

Discussion
Outpatient triage is a necessary service in many parts of the world, especially where primary care systems are weak and primary care physicians work short weeks (9).Outpatient triage can improve treatment efficiency, reduce hospital queuing time, and improve medical efficiency, better meeting patients' medical needs (3).With a shortage of medical staff, short consultation times for primary care physicians and non-24-h outpatient triage staff (9), we needed a tool that could help patients triage in real time.Traditional websites and apps can help triage patients, but the disadvantage is that the operation is complex, the information is broad and confusing, and cannot provide instant personalized feedback (10).However, this study shows that manual triage is highly consistent with ChatGPT triage and can provide professional, comprehensive, and humanized triage.ChatGPT can provide an interactive experience closer to human conversation, providing instant personalized feedback.Furthermore, ChatGPT possesses certain constraints, encompassing potential biases, reliability issues, privacy apprehensions, and ethical considerations surrounding its utilization (11,12).Consequently, it is imperative to consistently update, train, and enhance ChatGPT to guarantee the security and credibility of the information it provides.Additionally, ethical frameworks ought to be formulated to tackle ethical quandaries stemming from its application in healthcare.This study lacks a large multicenter study.For future inquiries, it is envisaged that we shall amass specimens from numerous hospitals, regions, and centers, thereby augmenting the sample size and executing a multicenter study.Additionally, the triage of outpatient patients utilizing other AI models will be evaluated and contrasted with the triage by ChatGPT, providing a comprehensive comparison of their respective efficiencies.In the future, we hope that ChatGPT triage can be operated in healthcare facilities, so that patients can have a more convenient and faster medical experience.It is anticipated that ChatGPT will attain broader adoption in the medical sphere in the foreseeable future.