If physicians feel like the cumbersome EHR inbox has become even more unbearable since the pandemic, the data shows they’re right.
Emails from delivery organizations, commercial pharmacies and patients land in physician inboxes on a daily basis. Before the pandemic, the average family physician spent about an hour and a half each day on the inbox. About 3% of messages were from patients. To safely manage these messages, physicians spend more time addressing each individual message compared to other types of messages in the inbox.
One study shows that patient messages increased by 57% at the onset of the pandemic and have remained at this “new normal” level, Christine Sinsky, MD, vice president of professional satisfaction at the AMA, and her co-authors wrote in the commentary “The Electronic Health Record Inbox: Recommendations for Relief,” published in the Journal of General Internal Medicine. The shift is an added burden on physicians.
“After two years, we observe that what patients desire and expect is different. Immediate access to one’s physician for non-urgent questions in real time is highly valued and can be valuable; direct access to one’s physician may even be advertised by institutions as a service differentiator in local competitive markets, and yet we have not yet developed the care teams and compensation models designed to deliver care in this way,” the commentary notes.
Committed to making physician burnout a thing of the past, the AMA has studied, and is currently addressing issues causing and fueling physician burnout—including time constraints, technology and regulations—to better understand and reduce the challenges physicians face.
Managing the “new normal”
Fundamental changes in how care is delivered happened in a quick two-to-three-month period without the workflows, teamwork and payment models in place to make the added work manageable. It’s left physicians—who have borne the brunt of the extra work—spending hours on clinical e-correspondences that would have been billable during a visit, the commentary says.
Meanwhile, relative value unit (RVU) productivity expectations haven’t changed, nor have the expectations for patient contact hours.
“The nature of care delivery for patients has fundamentally changed. To a point, diligent physicians took on the expanding inbox work as a contribution to the pandemic mission, but that mission is now receding and clinicians may be reaching a breaking point,” says the commentary. “Design of systems, changes to reimbursement, and staffing are now critical to allow the expansion of care delivery in this way without adding burden to an already overburdened healthcare workforce.”
With these challenges in mind, the commentary offers five recommendations.
Measure the volume of inbox messages. EHR-use metrics can quantify the volume and distribution of inbox work and the time that’s needed to manage it. Use the data to design teamwork and compensation models.
Reduce the volume of inbox messages. Turn off low-value notifications. For example, notifications don’t include a test result and only say that a test was ordered. Stop routine notifications to primary care practices of every test ordered in real time during inpatient care. Notify only the ordering physician’s practice of a test result instead of routinely notifying multiple physicians.
Strategically delegate remaining messages to a more robust team. For messages that can’t be weeded out by systematic processes, delegate an upskilled team member to research all the messages. Messages that team members can’t resolve independently can be addressed directly with the physician. An optimal team structure (two clinical support staff per physician in many specialties), stability (the same individuals working together each day) and skill level (nurses or medical assistants with supplemental training) will help ensure that inbox messages are delegated safely and efficiently.
Provide payment for this growing form of medical care. Develop evidence-based adjusted expectations for patient contact hours and RVU generation. Establish optimal staffing ratios to support the needs.
Advance research that quantifies the nonvisit-based work. Look at the differences across specialties; the risks and benefits of inbox care; and the effectiveness of interventions meant to reduce inbox burdens.
AMA STEPS Forward® playbooks can help physicians and their organizations tame the EHR (PDF) and save time (PDF).
