Physicians can spend an entire day caring for patients only to be confronted by a time-consuming and unpaid further demand on their time: patient portal messages. After the office has closed, physicians often must engage with the portal, and the EHR, sometimes long into the night, instead of having restorative time alone or with family and friends.
And though there’s no EHR “silver bullet,” according to C. Becket Mahnke, MD, chief medical information officer at Confluence Health in North Central Washington, much can be done to reduce the afterhours work, often called “pajama time.” Confluence Health is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Confluence Health is making real inroads in the fight against overwork. The amount of time that family physicians and internists spend in the EHR has dropped by an average of 34 minutes per eight-hour clinic day. They’re spending about 17% less time in the EHR and about 67% less time after hours compared with figures reported by researchers from the AMA and elsewhere.
Meanwhile, Confluence Health’s burnout rate among family physicians has fallen from 41% to 26% in the most recent survey. The work after work spawned by electronic patient messages and the EHR is both substantial and a driver of the overwork that often contributes to physician burnout and addressing this need has been a priority for Confluence Health.
As the leader in physician well-being, the AMA is reducing physician burnout by removing administrative burdens and providing real-world solutions to help doctors rediscover the Joy in Medicine™.
And though frustrations naturally abound about the patient portal, there can be positives in the experience—if leaders don’t allow it to overwhelm physicians.
“Let's make sure we do it the right way, so that we're not overworking our physicians and they're burning out and they're no longer there to serve their communities,” he said. “But I have yet to meet a physician that doesn't actually want an engaged patient.”
Taking time to save time
Part of the gains at Confluence Health were achieved by investing time to save it later. For example, Dr. Mahnke said, sometimes physicians are reluctant to create new note templates.
Too many physicians have failed to take full advantage of new notetaking rules, he said. Out of habit, he said, physicians may think, “Yeah, my template's fine. I know how to click through it. I'll just stay with my 10,000-character note.” But such notes are “painful for folks to read” and gobble up others’ time.
Therefore, it can be an easier sell to start with physicians who are new to the health system and will routinely create a new note template in any event, Dr. Mahnke noted.
“Behavior is really hard to change,” he said. “And routine is really hard to change.”
And making small changes to the way the patient portal works—for example, filtering out “thank you” messages, auto-closing message strings and giving self-service options—all help reduce the time physicians spend on tasks unrelated to patient care.
There are also clear benefits to creating automated processes, Dr. Mahnke said, giving an example of one large clinic where 80% to 90% of all messages are handled by staff members without physician input. That staggering figure was achieved by creating formulaic ways of handling different types of messages.
“And that's because they have created clear protocols for the people who receive these messages that if the patient requests this, do this. If the patient requests this other thing, do this thing,” he said.
The standard of care in physician well-being recognition
Institutions in this article have been honored by the Joy in Medicine™ Health System Recognition Program.
Setting patient expectations is key
Dr. Mahnke said it’s also crucial that patients understand how to use patient portals. He believes that the language in the portal often gives the mistaken impression that patients can constantly communicate one-on-one with their physicians.
“What I've asked, when presenting this in several places now, is, ‘Raise your hand if your doctors answer the front desk phone,’ and, of course, nobody raises their hand,” he said. “Saying that you're directly messaging your doctor is inappropriate because that's not how we provide the care, or not how we should provide the care. But that's the expectation that we've set.”
He said that it’s “not that the physician is high and mighty and needs to be protected, but we're using people at their skillset.”
Instead, he said, patients should know that messages are going to the care team, should use the portal in a way that is respectful of their physician’s time and should have appropriate expectations on turnaround.
Dr. Mahnke told the story of one colleague, a pediatrician, who received a message from a patient’s mother saying that she was on her way to the pharmacy and was expecting the child’s medication to already be refilled when she got there in 20 minutes. The colleague thought it critical not to reinforce patients’ reliance on such rapid response and, instead of immediately refilling the medication, spoke with a nurse and asked her to discuss the 48-hour message turnaround with the mom.
“That saved the physician a message, it empowered the nurse to do something, and it set expectations for the patient,” he said. “We can talk about it at the system level and the marketing level … but there's also a responsibility of the physician and the staff team to do that at the individual level.”
At the end of the day, Dr. Mahnke said, it’s important for physicians to be understanding with patients, with other members of the care team—and most importantly, with themselves—while they learn how to use what is, essentially, very new technology.
“I offer all of us grace because … at the core, this is a relatively new model of health care delivery, asynchronous electronic messaging between patients and their doctor's office,” he said. “And we're still learning how to do that.”
Learn more through an AMA STEPS Forward® toolkit on strategies about how to optimize the patient portal.
AMA STEPS Forward open-access toolkits offer innovative strategies that allow physicians and their staff to thrive in the new health care environment. These resources can help you prevent burnout, create the organizational foundation for joy in medicine and improve practice efficiency.
