How will this module help me more effectively manage my in-basket?
Details six STEPS to creating an optimal and orderly in-basket
Answers commonly asked questions about in-basket management
Provides tools to guide you and your team through the process
One consequence of adopting an electronic health record (EHR) is that the physician’s in-basket often becomes the default destination for most forms of communication in the office. As the physician’s workload grows, so does the volume of the in-basket, creating a burden that can be difficult to effectively manage during the day. The physician is then faced with spending long hours before and after clinic to complete “between visit” clerical work. For some physicians, this can add up to an extra one to two hours of work every day.1
A recent study found that physicians spend almost half of their day on the EHR and desk work. Even during the patient visit, 37 percent of the time in the room is spent on these tasks.1 The increase in clerical burden resulting from EHR adoption was cited as a contributor to physician dissatisfaction in practice and subsequent burnout.2
The reality is that the majority of in-basket messages in many clinics do not need to be routed to the physician. This module will help you keep unnecessary messages from being routed to your in-basket in the first place, guide you through establishing a centralized team in-basket, and suggest ways to empower team members to contribute in a meaningful way to in-basket management.
“At Bellin Health, we’ve worked hard to redistribute in-basket workloads. An effectively managed in-basket leads to more timely patient care, with the work being distributed to appropriate members of the care team rather than the individual physician. It takes a team to make in-basket management efficient, and this team approach ultimately leads to better, more timely patient care.”
James Jerzak, MD, Bellin Health, Wisconsin
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Six STEPS to create an optimal and orderly in-basket
Engage IT to prepare for restructuring your in-basket
Identify the types of messages that could be routed to other team members
Work with IT to restructure your EHR to direct messages to the right team members and declutter your in-basket
Create a team pool and team pool in-basket to help redistribute and streamline work
Empower staff to contribute by utilizing principles of team-based care
Develop workflows for common in-basket tasks
STEP 1 Engage IT to prepare for restructuring your in-basket
Let your IT team know that you’ll need their help to restructure your EHR with the goal of optimizing your in-basket. You could start by obtaining a list of all possible in-basket folders, and meet with IT to eliminate or consolidate these to simplify the work. You may find that they have suggestions or advice to overcome challenges and make the transition easier on everyone.
STEP 2 Identify the types of messages that could be routed to other team members
Quiz Ref IDStep description: EHR systems often have dozens of categories of messages. Here are three overarching categories to consider when you set out to optimize your in-basket:
Those that require direct physician management
Those that can be routed to other team members
Those that are not relevant to patient care or clinic business and should be filtered or deleted
Re-directing certain types of messages to a medical assistant (MA), licensed nurse practitioner (LPN), registered nurse (RN) or patient services representative (PSR) on the team can help lighten your workload. Practices have successfully shifted refill requests, referral requests and general patient questions to MAs, RNs or LPNs.
Some practices, particularly those with one or more RNs on the core team, have routed all in-basket messages to the clinical support staff. In this model, messages that require physician input are first researched by the nurse, addressed verbally with the physician and then the response is operationalized by the nurse. This type of team-based approach could save an hour or more of physician time per day.
STEP 3 Work with IT to restructure your EHR to direct messages to the right team members and declutter your in-basket
Quiz Ref IDIT support is essential for establishing a manageable in-basket. Ask your IT team to help you configure the filtering capabilities of your EHR to decrease the number of items you are not actively managing.
Next, ensure that the appropriate types of messages are coming into your in-basket. Consolidate essential messages if possible and eliminate any that don’t truly need your expertise.
Lastly, get rid of old and/or duplicate messages. An excessive volume of old messages in in-baskets can slow down the speed of the entire EHR. The Bellin Thedacare EPIC system at Bellin Health in Green Bay, WI, for example, had almost five million messages over one year old in their system. After notifying the clinicians, the system was purged of these messages, which greatly improved EHR speed and allowed for faster in-basket refreshing. Duplicate messages or reports should be avoided at all times.
STEP 4 Create a team pool and team pool in-basket to help redistribute and streamline work
Quiz Ref IDIn addition to the physician’s in-basket, many practices also have separate in-baskets for triage, refill requests and patient questions. It is often difficult to determine where various messages or results should be sent and which team members should be checking the numerous in-baskets. Messages can end up in the wrong basket, and with multiple care team members checking these baskets, any breakdown in communication or documentation can cause duplication of work. Messages or results may fall through the cracks because no one knows they haven’t been addressed or completed. This poorly organized process creates confusion and is inefficient. One way to bring clarity and order to in-basket work is to create a team pool.
In a team pool structure, each physician or advanced practice provider has their own core team of MAs/LPNs/RNs who are always assigned to the pool. Only these core members can sign into the team pool in-basket. It is advantageous to form this cohesive unit because everyone is familiar with the physician’s patients and their care plans. A single in-basket for this team pool fields all requests for that physician. Items such as patient questions, results notes, refill encounters, and carbon copied charts are sorted into to sub-folders within the team pool in-basket. The MAs/LPNs/RNs working with that physician are permanently checked into the team pool, which allows them to handle these items for their team to the top level of their licensure. With this approach, any high priority messages can be rerouted to the physician’s in-basket or the physician can be verbally notified that something requires immediate attention.
“Time management is crucial! Do small tasks in between patients—everyone thinks they don’t have the time, but even in a couple of minutes you can get a result or refill done. When your physician is in with a long appointment you could get more in-basket work done.”
Jami Burroughs, MA, Bellin Health
STEP 5 Empower staff to contribute by utilizing principles of team-based care
Empowering and trusting staff, encouraging critical thinking and always putting the patient’s needs first are team-based care principles that support efficient in-basket work. In general, the core concepts for successful team-based care apply directly to in-basket management. This includes co-location, where the team members’ and physicians’ work stations are in close proximity, along with standard messaging and communication. Here are some team-based care techniques that could contribute to your success.
Co-locate team members. It may seem counterintuitive, but in-person communication is a key component of effective in-basket management. Co-location is a principle of team-based care that promotes verbal communication between all team members, resulting in less need for electronic communication that clutters the in-basket. Consider co-locating team members such as triage nurses, rooming staff and schedulers. This will facilitate prompt resolution of questions or issues that arise during triage, rooming and scheduling. While face-to-face communication is ideal, if co-location is not possible in your clinic layout, find another way to enhance communication between team members to decrease the need for electronic messaging. Some practices use secure mobile or text-based platforms such as Vocera, TigerText or Imprivata® to improve communications, whereas others keep in contact with walkie talkies.*
Incorporate a daily huddle. Daily huddles can help you reduce unnecessary electronic communication. For example, you may use the huddle to identify appointment times for additional patient access that day instead of messaging back and forth.
Empower staff with new responsibilities and autonomy. Empowering staff to make decisions and take on additional tasks is a valuable technique for cutting down on messaging. Consider training rooming staff to make decisions regarding additional patient access as the need arises. Or, you could create protocols to enable rooming staff to pend refills for 90 days with refills at appointments for annual checkups or chronic disease management. If there is hesitancy to refill all meds for one year, start with a safe chronic medicine that doesn’t need close monitoring such as a statin, metformin or calcium channel blocker. Training can take the form of professional development programming to help your team members perform to the top of their licenses.
Start using pre-visit laboratory testing. Pre-visit labs rely on scheduling labs for the next appointment before the patient leaves. Results are sent in advance of the next visit. With protocols in place, empowered staff can perform a preliminary review and flag those that are abnormal to save time for the physician. In some practices, the MA or nurse will research the patients’ previous abnormal labs (e.g., for a low potassium result, the nurse may call the patient to determine adherence to medications and provide this information to the physician along with the cumulative trends of the lab result, the medication list and last visit note). The nurse may verbally review accumulated messages with the physician several times per day, allowing the physician to efficiently make safe, informed decisions.
Use verbal messaging rather than electronic messaging whenever possible. Verbal messaging is more efficient and is a richer form of communication. It is supported by co-location, but can be the predominate form of communication in any setting.
STEP 6 Develop workflows for common in-basket tasks
Creating standardized and simplified workflows will help everyone on the team perform more efficiently. Here are some examples of areas where you can start:
Standardize prior authorizations. Develop standardized workflows so that your team can fill out prior authorizations as much as possible before coming to you for completion or signature. This approach shifts the bulk of this task to appropriate office staff working to the top of their skill set. Consider developing a centralized prior authorization team composed of RNs and MAs. Maximize the use of generic medications to minimize the need for prior authorizations and be sure the patient is adhering to their current medications before adding or escalating therapy.
Eliminate, automate or centralize repeated tasks. First, try to decrease the need for repetitive work. For example, with medication refill requests, synchronized bundled renewals can markedly decrease the volume of refill requests. Second, for those refill requests that still come through, consider an automated refill request system or a centralized refill team. This may be the same team that handles prior authorization requests. Eventually, you may want to extend this standardized approach to handling requests for controlled substances refills.
If your practice sees a high volume of patients on oral anticoagulants, consider developing a centralized INR management team to handle these results per protocol. If your clinic has an embedded pharmacist, adding them to your team pool to manage in-basket tasks related specifically to these patients could be valuable.
Quiz Ref IDSimplify form completion. Timely completion of paper forms in the in-basket is always a challenge; however, if paper forms are not handled expeditiously, the originator of the form will likely send a second request, which then doubles the work. Specific workflows and defined responsibilities are necessary for this paperwork to be as complete as possible. Assign forms to appropriate team members to be filled in so all you need to do is review and sign. Other team members can easily complete the date of last visit, diagnoses and current medications. Attaching a printed list of medications instead of writing the medications out may save time and reduce errors.
Delegate screening of portal requests. Patient portal messages should not go, by default, directly to the physician. Have these messages screened by appropriate staff, and completed by them whenever possible. The use of team pools allows these messages to be routed to the appropriate team member who can handle the requests.
Anticipate the needs of complex patients. A robust transitional care program for complex patients leaving a hospital or SNF could avert complications. Anticipating and meeting their needs before a crisis may in turn decrease in-basket work and phone calls to the office.
Managing the in-basket should not rest solely on the physician. There are many ways to reduce the amount of time spent on this task. Leverage the skills of the care team to apply the principles and workflows of team-based care to be more efficient, redistribute the in-basket workload and ultimately get more done during the clinic day.