AMA Update covers a range of health care topics affecting the lives of physicians, residents, medical students and patients. From private practice and health system leaders to scientists and public health officials, hear from the experts in medicine on COVID-19, medical education, advocacy issues, burnout, vaccines and more.
Featured topic and speakers
What is virtual primary care? Should you reply thank you to your doctor? What is a virtual care physician? How do doctors use EHR secure messaging?
Our guest is Matthew Sakumoto, MD, virtual-first primary care physician and chief medical information officer, at Sutter West Bay Region. Dr. Sakumoto shares his best practices for EHR inbox messaging and how physicians can create a personal connection, set expectations and more when caring for patients via text. AMA Chief Experience Officer Todd Unger hosts.
- The AMA is your powerful ally, focused on addressing the issues important to you, so you can focus on what matters most—patients. We will meet this challenge together. Join us.
- Learn more about our AMA advocacy priorities, including:
- Reforming Medicare payment
- Fighting scope creep
- Fixing prior authorization
- Reducing physician burnout
- Making technology work for physicians
Speaker
- Matthew Sakumoto, MD, virtual-first primary care physician and chief medical information officer, Sutter West Bay Region
Transcript
Unger: Hello and welcome to the AMA Update video and podcast. Today we're talking about best practices for inbox messaging with Dr. Matthew Sakumoto, a virtual first primary care physician and chief medical information officer at the Sutter West Bay region of Sutter Health in San Francisco. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Sakumoto, welcome.
Dr. Sakumoto: Thanks so much. I appreciate the mouthful of a title. I wear many hats.
Unger: Well, I'm interested in your title because I think it might be the first time I've ever seen of this idea of virtual first physician. And so why don't we just start there? How did this happen? How did you become a virtual first physician?
Dr. Sakumoto: Yeah, I really liked the idea of providing care beyond clinic walls. So I think that really helps out. And one way to do that is through telehealth and other means of connecting with patients virtually. You can only fit so many patients through the doors of a clinic in a day. You can really multiply that and have that effect otherwise.
So I've been playing around with it before it was cool. So I was doing telehealth prepandemic, but the pandemic time really gave me a chance to hone those skills and teach them as well to my colleagues and some other folks.
Unger: I like that you were doing virtual before it was cool. A lot of the conversations we had over the course of pandemic was what are the skills that are needed for that new virtual environment. Are you finding that physicians are starting to specialize in one or the other channels, or is this kind of a combo thing?
Dr. Sakumoto: I think for the most part, it's a combo thing. I will say there's a learning curve. It felt like I was going to medical school again. How do you do a virtual physical exam? How do you reach the patients through video?
And then as we've really pushed a lot of care to the in-basket and that asynchronous thing, it's like, how do you actually elicit a good history from a patient essentially just through text messaging? It's secure messaging with the patient through the electronic health record.
Unger: Well, before we get into the inbox messaging, which is the theme of this particular update, what's your day look like? How does a virtual first physician operate?
Dr. Sakumoto: There is no typical day. And I think that's the beauty of it. It's really unstructured. It's traditional primary care. I share an office with a bunch of my colleagues and they have a morning session and an afternoon session, rinse and repeat, each of those days.
I have a lot of what I call unstructured time. So I'll message with a patient and if it seems like they need to have a video visit or even an in-person visit, we can up-triage that in the moment. So it's one of those things where it adds flexibility. I mean, to my day, but also we get the right patient to the right level of care at the right time, which I think we're very—have difficulty doing the traditional 15-minute slot that you can put people into or not.
Unger: Well, let's talk a little bit about this idea of inbox messaging. In past conversations, we've talked about inbox messaging as one of those things that's really been overwhelming physicians since the pandemic and creating a lot of burden that can lead to burnout for some folks. But for you, this is part and parcel of the day. So let's talk a little bit about what you've learned as far as best practices go around inbox messaging. And for starters, how do you acknowledge a patient's message?
Dr. Sakumoto: I think a lot of it is how do you keep that conversation with a patient going without it feeling transactional? And I think that's the biggest thing. So a lot of times I think patients and we're used to the cult of now. So you can order things online and it arrives within the same day.
So I think that level of—or you can call a cab or call an Uber or Lyft and it arrives in the moment. So I think we've consumerized ourselves to want to have a post-immediate answer. One thing that I think is super important is acknowledging receipt of the message. I think a lot of patients feel like they send a message in and it sort of goes out into the ether.
So just saying like, hey, we got your message and these are the next steps. So it provides that level of just closed-loop conversation and gives them a sense of ease. So that's what I realized is—what I used to do with some of my colleagues and still do is they want to be able to provide the patient with a full answer. So you look it up, it takes a few days to collect that up. So being able to provide the patient with, 'Hey, we hear you, we're working on this and here's about the ETA of when we can get back to you.'
Unger: I like that. And I think that's something people are used to from other environments when they ask for help, they get a message back and it says, we got your message and we'll be back to you. So I think that makes sense. It's what people expect now. Here you can settle that for me, though. When I do hear back from my physician, should I send back another note that says thank you or should I just alleviate the burden of another email?
Dr. Sakumoto: This was a thing of great debate—I think you should still say thank you. It's one of those things where it doesn't add an extra ping to in-basket. Yes. But it's a nice little note. So I would still say, yes. It's worth putting in that thank you.
Unger: I love that because I'll tell you what, I'm so protective of physicians' time that I don't do that and now I feel bad, but I'll change my ways. Dr. Sakumoto, the personal connection between a patient and a physician is, of course, so important. Got to be a little bit harder to do through email and through electronic messaging. So how do you think about the idea of creating a connection through a text or an email message?
Dr. Sakumoto: Yeah. And I think a lot of it is personalizing that message. So we're an Epic shop at Sutter, so there's a lot of prefabricated phrases that you can use. And I used to really focus on efficiency. And then I realized that like, no, it's actually better to personalize it.
So the extra—and I'll be honest, it's an extra five seconds to add even a little tagline on the front end for the patient is worth the time because it feels like you've personalized it for them. I've had patients say like, 'Oh, I thought it was just a bot that was auto-responding.' I was like, 'Oh, no, that was me.'
I guess I was kind of auto-responding because it was a copy-paste answer. So when I got that feedback from patients, I started to really personalize it. I liken it to getting the rare handwritten thank you note these days. So it adds a nice personal touch.
Unger: A handwritten thank you note. What is that? So that is very nice to just personalize what otherwise would be perceived as a bot message. I love that. Now, it's kind of setting expectations with your patients over messaging. That's got to be pretty important because it is relatively new in health care. What does that look like? How do you set the appropriate parameters?
Dr. Sakumoto: I think it's a learning process. So we actually have almost like a welcome message to the patients. I think that just says like, hey, if there's certain things like refills and you've established with us, just let us know. So there's little things that say, like, hey, these are the things we can do quickly. And also give us at least two or three days to get the refill done.
We can't respond instantaneously. So it's one of those—we're fast, but we're not instant, I guess, is kind of setting that expectation with them. I think the other thing too is having—we work as a team, so having that expectation be communicated clearly across all team members as well, because you don't want one person to over-promise, and I guess, ultimately me to under-deliver. So having the team, the care team all agree on what those—it's particularly around time to response, but also what is appropriate to be handled over messaging or not from a clinical standpoint.
Unger: Yeah, that's interesting. And I think people are so used to immediate responses from friends and family members. It doesn't work the same way. I did have a physician say like, 'I got back to you in 24 hours. That's pretty good.' And I was like, 'You know? You're right.' And so that did change my frame of reference.
But the other thing you just talked about was like, what's appropriate to have in terms of a conversation in these asynchronous methods where sometimes the whole point doesn't come across or it's a lot of back and forth, like, what point do you just got to pick up the phone and talk to somebody?
Dr. Sakumoto: Yeah. I think of it like if you are messaging with a friend or a family member and after three or four that text message back and forth, you're like, you know what, let's just like hop on the phone and hash this out. So I think there is some level of that as well.
And again, that's why my days are unstructured. So if it seems something's like, ah, we can't quite get this through messaging, picking up the phone, setting up a video visit if I need to evaluate something visually is there. So I think that's the beauty of the flexible schedule, too, is if I was in a traditional primary care setup, I'd be like, well, it looks like I'm booked out for the next three weeks, so maybe I'll see you then.
Now it's like, are you free in the next hour? Let's hop on a call. So that level of flexibility really also builds patient trust and confidence in us as well.
Unger: Now, I like that because through your experience and through the way that you've structured your day, you have that flexibility to be able to operate in a virtual first environment. These are the kinds of, I guess, principles or frameworks that people need to use that they think about this as opposed to being, I guess, kind of more opportunistic about it.
So let's talk about how do you put principles like this and your experience that you've developed over the course of time into practice and take that to the organizational level in terms of systems.
Dr. Sakumoto: I think the biggest shift that we've thought about is this doesn't really work in the traditional fee-for-service world. A lot of things that I'm doing—you can charge for patient messages, but that doesn't come close from a financial standpoint to just seeing 30 patients a day. That being said, seeing 30 to 40 patients a day is also not very sustainable.
So I think it's the fundamental incentive structure and shift around that I think is most important. So how do we look at it? We look at a patient's journey holistically. And the way we're able to do that is through more value-based care setups. So HMO or health maintenance organization, capitated contracts, or some of the value-based shared savings programs, but this idea of how do you just make sure that the patient stays healthy, stays out of the hospital, stays out of the emergency department.
Once you have that focus flipped towards there all of this starts to make sense where it's like, oh, you don't have to see a ton of patients per day. It's not number of patients seen, but number of patient lives impacted. That is really the unlock for this virtual first style of care.
Unger: It's interesting. I mean, of course, we started with virtual care, at least the acceleration of it during the pandemic and now we're going into a different phase. Do you see Sutter at an operational level starting to think about how do we divvy this up between the traditional way of seeing people? You talked about fee for service in that regard and then this virtual first kind of care at a system level.
Dr. Sakumoto: We're seeing different things and I can speak to at least what we're doing here in the San Francisco region. There's a mixed team, multidisciplinary in-basket support team. So what that does is it's not quite virtual first care, but it can help unload some of that burden for the docs that are really in the clinic in person.
So it's a team of medical assistants, pharmacists, nurses that can really take that first pass at a message. So going back to our earlier point of, how do you respond fast but not instantaneously to patients? That's another way to provide team-based care and get patients the care that they need.
Unger: I love this. So many times we talk about technology and the thing that gets discussed over and over again it's not just the technology, it's the people and it's the systems and the approaches and principles that all bring it together. You've been doing this now for a while. Can you talk a little bit about some of the results that you're seeing?
Dr. Sakumoto: Yeah. The way that we focus on this is really taking the—I guess what we say as triple aim, maybe quadruple aim, pulling it up, the quintuple aim. But really, first and foremost, what's best for the patient. So how are the clinical outcomes?
Our ability to, again, provide care beyond the clinic walls means that our quality metrics are great. So usually, we do a really good job—or traditional care does a really good job for patients that show up to clinic. We can make sure that they get their cancer screenings and get their diabetes screenings for us because we think of them as an entire panel.
Even if they're not walking in through the clinic doors, we're doing outreach to them by phone and by messaging to make sure that they also close those care gaps. So I think our clinical care gap closure has been great just from a patient quality standpoint.
Cost of care is another one. So I think that's another piece where we're able to provide messaging-based care. And again, our whole goal is to really decrease unnecessary ED hospital utilization. So that can really just drive down the cost of care from that standpoint. And increasingly, we are putting a really big focus on digital health equity and health equity in general.
So not everyone has access to a smartphone or the ability to do video visits, so how do we make sure that stays equitable. So that one I will fully admit is a work in progress, but I think that's super, super important in terms of making sure we can reach as many patients as possible.
Unger: Absolutely. And you mentioned the triple aim and the quadruple aim with the difference being, one, taking good care of physicians as they try to take care of patients. Do you feel like, I don't know, the expansion of this particular virtual first will be a step forward in taking care of physicians as well?
Dr. Sakumoto: Oh, definitely. Thanks for that reminder. Yes. So for the clinical team—physicians, in particular, but I think the clinical team in general, there is this high level of autonomy. I think that's brought back to practice again. Before, as I mentioned, other people tend to slot patients into your schedule. This one, you have one, the flexibility for the patient, but also that level of being able to deliver the care that the patient needs in real time I think is really great.
The other nice thing about this is we intentionally create them as pods. So I work with the same medical assistant and the same—either nurse practitioner or physician's assistant. So there is this level of—it almost feels like a team sport, especially when we're doing messaging.
So sometimes the MA will take the first pass with the patient. I'll respond back, the MA will respond with a third message. So it's almost like basketball where you're passing the ball around. And that team sport feeling really does—it kind of protects against burnout because you feel you're part of a team.
Unger: Well, I love this conversation. And it reminds me that one of the five pillars of our work at the AMA is making technology work for physicians and not vice versa. And this is such a great example of how you're making it work, both for you and your patients.
If you'd like to learn more about the best practices that we discuss, I encourage everyone out there to check out the links in this episode description. You'll find a webinar featuring Dr. Sakumoto and more AMA resources. To support our work, we encourage you to become an AMA member at ama-assn.org/join.
That wraps up today's episode. We'll be back soon with another AMA Update. Be sure to subscribe for new episodes and find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
Subscribe to AMA Update
Get videos with expert opinions from the AMA on the most important health care topics affecting physicians, residents, medical students and patients—delivered to your inbox.
