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Featured topic and speakers
A strategy and tactical tips to reduce your EHR inbox and save time. Atrius Health has reduced EHR inbox volume by 25%. Joining us to share how they did it is the physician who led the effort, Jane Fogg, MD, MPH. AMA Chief Experience Officer Todd Unger hosts.
- 📨 Get the 9 Step System-Level Approach to EHR Inbox Reduction (PDF).
- ✅ Download the EHR Inbox Reduction Checklist (PDF) now.
- 📺 Watch the system-level approach to EHR inbox reduction webinar.
- 📋 Access AMA’s Taming the EHR Playbook.
- 📰 Read the full In-Basket Reduction article in New England Journal of Medicine (NEJM) Catalyst.
- 🗓 Learn more and register for the American Conference on Physician Health (ACPH), Oct. 11-13, in Palm Desert, California.
- 💪 Learn how the AMA is #FightingForDocs and access resources from the AMA Recovery Plan for America’s Physicians.
Speaker
- Jane Fogg, MD, MPH, physician leader and health care executive, Atrius Health
Transcript
Unger: Hello. And welcome to the AMA Update video and podcast series. Today, we're talking about some tactical ways to reduce the burden of your EHR inbox. I'm joined by Dr. Jane Fogg in Brookline, Massachusetts. Dr. Fogg is a physician who's practiced primary care and held multiple leaderships for the last 25 years. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Fogg, we're so glad to have you today.
Dr. Fogg: Thank you, Todd. Glad to be here.
Unger: Well, reducing burdens and burnout are both huge priorities for the AMA. And we're so excited to talk about your work with physicians. Most recently, you led a team at Atrius Health that started an initiative to reduce EHR inbox volume. And you made some impressive progress. So let's start out. Just how much of a reduction did you achieve? And how much time did that free up for the clinical staff?
Dr. Fogg: So we started this work in 2016. And since then, we reduced the in-basket volume for our PCPs by 25%. That's a significant improvement. But it's clearly not enough. We started with about 100 messages per day for a full-time PCP. So we have more work to do, but we've made a nice dent in the volume.
We are trying to measure the time saved. And that always proves to be a little more challenging just with the limitations on measuring actual time. So we don't have those figures yet, but we are working on it.
Unger: Now, I'm sure that making progress like that requires system-level change, not just kind of the tactical work there. Can you talk about at a high level the different kinds of approaches that Atrius Health took?
Dr. Fogg: We employed a strategic framework that really helped drive our work forward. Specifically, we had four tactics that we used. We asked, what can we eliminate, completely remove from the in-basket of the PCP? What can we automate, embedding an automatic protocol into the EHR that resolves the task without the PCP's intervention? What can we delegate? We typically delegate to staff all the time. But how can we enforce delegation by embedding it in the EHR protocols?
And finally, where can we collaborate? The in-basket is team-based care. And so whether we're collaborating across our team, across specialties, or even across departments, how can we find ways to have shared accountability for the in-basket? Those four tactics helped us achieve the 25% reduction.
Unger: So I love a good framework. Eliminate, automate, delegate, collaborate. I also love to hear more about some of the specific tactics that you used at Atrius Health. Let's start by talking about another acronym here, PMAR, or Patient Medical Advice Request. What steps did you take to make those messages more manageable?
Dr. Fogg: This has been a hot topic across the country, as all of us have experienced a major increase in PMAR messages from our patients as they become more comfortable using the portal to access care. We didn't use this tactic early on because it used to be a small fraction of our daily messages.
As the volume grew, we employed embedded delegation and collaboration into our EHR. Specifically, rather than having the message go straight to the PCP to determine if they should then send it on to somebody else, we sent it straight to one of our clerical staff members.
That member can see what they can resolve themselves, what they need to delegate up to someone clinical such as a nurse, and then finally, what still might need to go up to the physician or advanced practice clinician because it does require their input. Using that tactic in the sites we've employed this, we had a 40% reduction in what goes to the PCP's in-basket.
Unger: Well, that's huge. And now, is this because patients are becoming more comfortable corresponding with their physician through these portals?
Dr. Fogg: Absolutely. The COVID pandemic really shifted things for everyone across the country. And we're glad that patients are more comfortable using the portal. But we didn't actually design our teams or our IT infrastructure to manage it. So this is a first step in trying to reflect how we should manage these messages.
Unger: That makes a lot of sense. And I'm curious if there is a role then too besides that kind of human intervention to use automation to kind of increase that reduction that you've already seen such a significant change in.
Dr. Fogg: Automation has been one of the most exciting things that I've been able to implement in this work. There are many routine repeated tasks that occur in primary care, one of them being prescription renewal requests. These requests come from patients, but they also come from pharmacies and many other sources. And in 2017, the average PCP was receiving about 16 a day. Many of them just require a simple check of the chart.
What we ended up doing is embedding an automation protocol into the EHR. The protocol checks for any outstanding care needs. Does the patient need an appointment? Do they need any lab work done? And so on. If everything is—passes and they're up to date with their care, we can automatically renew the medication without asking the PCP to do that. That's reduced the renewals in the PCP's in-basket by 50%.
Unger: Again, another incredible number. And 16 a day is a lot. That sure would add up over the course of the time. And to think about all the time that it goes in just to do the things that you outlined there that can be automated. Curious if there's one type of message in the inbox that you discovered you were able to just eliminate entirely.
Dr. Fogg: Yeah, there were several. One that was very exciting was actually the automated messages that we get from various hospitals about when a patient is in the emergency room, or being admitted or discharged. These were automated feeds that came straight to the PCP. And unfortunately, you might receive six or seven messages for one admission on your patient. And many of the messages didn't carry any content or clinical value.
So we took all of those feeds and we created a dashboard that the PCP can open up at any time and find out who of their patients are in the hospital, or recently discharged. This completely eliminated that message type. What was also important in this work is that we have nursing workflows to ensure that we are calling patients after admission and getting them into the practice. So we continue to make sure that we were on top of our patients, but not relying on these messages in the in-basket to do that.
Unger: Now you mentioned before something we may have heard before, which is kind of where the technology gets ahead of the workflow in that were—you end up in a situation where you're underprepared for what might happen in terms of the torrent of the kind of messages. So the work that you're doing to kind of triage and respond to these messages, it obviously involves, at a system level, the entire clinical team. It's not just the physicians.
And so to ensure that your inbox reduction effort was successful, what kind of stakeholders did you have to bring to the table?
Dr. Fogg: We brought in a wide range of stakeholders. I'd say first and foremost, in-basket is a reflection of team care, and it's a reflection of how you're using your EHR and technical systems to deliver care. So our first partner was our IT team. We have a very proactive and creative team who sat down at the table with us when we were trying to figure out where we would even start. They taught us things that we clinicians did not know about how the in-basket was designed.
And it created new ideas for us. We realized there were things we could change that we didn't even know existed. The other group of stakeholders was really the entire team, nursing, clinical pharmacists, operations, all of our administrative folks. It really was a team effort because we are, again, thinking of the in-basket as team-based care.
We certainly have projects where we brought in our legal department to talk about delegation, scope of practice, and I think in all of those endeavors, we walked forward with the idea that we want to give safe, reliable, great care, but put less of the burden on the PCP to direct all of it.
Unger: And exactly those points you talked about. System-level changes, team-based care, these are, of course, highly aligned with the work that's going on here at the AMA and our practice sustainability and satisfaction team working on a lot of that initial research that showed the gains that can be made on simple things like managing the EHR inbox and looking at some of these systems.
Now, you've been working with the AMA. I'd love it if you could talk a little bit about that collaboration and how EHR reduction has led to reducing physician burnout.
Dr. Fogg: The AMA has been incredibly supportive of physician well-being and of transforming care to not just serve our patients as well as we possibly can, but also ensure that our teams, our physicians, primary care in particular, can do their job with some joy. And so I'm really grateful for the collaboration. We—I will be speaking with several others at the American Conference on Physician Health, which is in October in Palm Springs, and a conference dedicated to talking about these subjects, and sponsored by the AMA and others.
I've done some conferences as well at UCSF and other places with the AMA, and also created a STEPS Forward module with an attached webinar for those who don't want to read it. And that really outlines more specifically the tactics we used and lessons learned. So grateful to the AMA for promoting this work, and partnering on it.
Unger: And just for the folks out there, you mentioned STEPS Forward. This is a set of modules geared toward helping reduce physician burnout, looking at those kind of system-level changes that can make a big difference. And encourage everybody to check those out on the AMA website. Dr. Fogg, big system-level changes, even tactical changes. They take a lot of work. There are a lot of lessons, I'm sure, involved in the effort that you made here. What's one big piece of advice that you might have for physicians and health systems out there that want to undertake a similar effort?
Dr. Fogg: I would advise folks to first understand your current state, why your in-basket is designed as it is, and how the decisions have been made. And then ask questions. I think you will find there are many opportunities to reroute, to eliminate, to change how things go in the in-basket.
And when you ask questions about why we're sending it to the PCP, you may find that there are—sometimes, there's no decision that was made, that people just got accustomed to routing something to a PCP when it really doesn't need to go through that process. So start by understanding your current state and ask questions about why.
Unger: Great advice. Dr. Fogg, thank you so much for joining us today and sharing your insights. Reducing burnout is one of the key pillars of the AMA's Recovery Plan for America's Physicians. And in the description of this episode, you're going to find a link to a comprehensive playbook that we've put together to help you reduce the burden of your EHR, something we hear a lot of requests for. The playbook includes a nine-step process guide, a checklist and more advice from Dr. Fogg and the other health systems to help you get started, save time, something I know you'd like to do.
If you'd like to hear more from Dr. Fogg at the American Conference on Physician Health, we've also included a link to register in the episode description. We'll be back soon with another AMA Update. In the meantime, you'll 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 podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
