The volume of patient portal medical advice-request messages and patient telephone calls rose noticeably during the COVID-19 pandemic. But while the number of calls have since stabilized, the number of portal messages have “meaningfully increased” compared with before the public health emergency, according to a study published in JAMA Internal Medicine.
“Patient-initiated medical advice-request messages increased substantially at the onset of the COVID-19 pandemic as other forms of care access were limited,” the study says. “These results suggest that the increase in message volume is likely a sustained, ongoing source of physician work.”
It also notes that the growth in volume has been greatest among primary care physicians and that time spent in the EHR responding to inbox messages has been associated with physician burnout.
“The study demonstrates the challenges that physicians face in doing all the work that needs to be done, and when the EHR requires so much of our time yet direct patient care is where we know we provide the most value,” Christine Sinsky, MD, vice president of professional satisfaction for the AMA and a co-author of the study, said in an interview.
“It is new work that has come on the scene in the last five to seven years and, oftentimes, it's very valuable work,” Dr. Sinsky added.
From AI implementation to EHR adoption and usability, the AMA is fighting to make technology work for physicians, ensuring that it is an asset to doctors—not a burden.
Challenges and opportunities
While patient-portal messages can have benefits, Dr. Sinsky said the current ways of responding to patient messages need to be made more efficient.
“The portal isn't always the best channel, but it's the path of least resistance that we've made available for patients,” she noted.
“So we need to both eliminate some of the inbox work that isn’t high value and then design physician's time, workflow and practice teams so that we have the capacity to do the high-value work and so we have the capacity to address patient's concerns via the portal when that is the best channel,” she added.
Taming the EHR portal inbox is a subject that Dr. Sinsky has devoted considerable time to.
In an AMA webinar that focuses on a system-level approach to EHR inbox reduction, she noted the need to set proper boundaries on patient portal use.
“But the bigger point is communication with one's physician through the portal is highly valued by patients,” Dr. Sinsky said. “We need to acknowledge that there is a significant new body of work that physicians are being asked to do, and we need to plan for that in terms of how the day is scheduled and in terms of the amount of team support that physicians have.”
For the JAMA Internal Medicine study, researchers examined monthly aggregated, physician-level deidentified EHR data—including the number of messages received—from more than 280,700 outpatient physicians from June 2019 through March 2022.
At the end of 2019, primary care physicians were receiving about 10 medical advice messages and 18 patient calls per week. This jumped to 16 messages and 24 calls in March 2020.
During the period studied, primary care physicians’ EHR time during off hours rose 6.5%, from 10.6 hours to 11.3 hours a week. During the same period, medical subspecialists saw a 9.9% increase and surgeons’ time rose 5.2%. EHR time for primary care physicians having more than 40 visits a week went up 7.8% to 15.2 hours from 14.1.
Dr. Sinsky referenced a study that found physicians in the top quartile for messages received had more than six times greater odds for burnout than those in the lowest quartile.
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Reducing the inbox burden
She offered four tips for reducing physicians’ inbox message burden:
- Go upstream to reduce the number of messages that are coming in to the inbox in the first place. Most organizations can reduce the inbox volume by 50% by eliminating redundant notifications and other “sludge.”
- Empower nurses to manage most messages.
- Make it easy for patients to use the inbox appropriately by helping them find the best way to connect with their practice, which may be by phone, message or scheduling an appointment.
- Provide full inbox coverage to physicians when they are on vacation, which can be done by having a nurse inbox manager for the practice.
The amount of time physicians spend in the EHR and responding to messages has risen greatly since the start of the COVID-19 public health emergency.
“There's new work that's being required of our physicians—particularly our primary care physicians,” Dr. Sinsky said.
“We have to build systems that make room for that new work that don't just assume that physicians will add that to an already full day or will somehow magically find time to do this new work while still doing the previous work,” she added. “Systems should block time for this work and should pay physicians for this work.”
