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Restructuring EHR In-baskets in Green Bay, WI: A Case Study

“I was at a conference recently and checked my inbasket—it was amazing to see things getting done by my team with our standing orders and protocols. Setting up processes to handle these tasks and then empowering the team to do it really works!” says James Jerzak, MD, Physician Lead, Team-based Care, Bellin Health Ashwaubenon.

Not long ago, inbasket management was very disorganized at Bellin Health Ashwaubenon (Bellin), a family medicine practice in Green Bay, WI. “We practice standardized rooming, but each medical assistant had seven or eight inbaskets they were checking throughout the day. No one knew what was going on or where they were supposed to be. We needed a process to keep on top of the inbasket and to make sure that the right team members were handling the right messages,” said Jami Burroughs, CMA. To understand the extent of the disorganization, they performed an audit of inbasket communication and then used this information to guide improvements.

Physicians, nurses and medical assistants (MAs) worked together to look at all the inbasket subfolders and categorize the types of messages that came to each folder. Commonly received messages included symptoms-based calls, requests for refills, appointments, medical records, orders, results and questions about immunizations, medication or a recent office visit. Then, the group determined if what was coming into each folder was useful or redundant. They filtered out information that the recipient was not directly responsible for managing and evaluated which team member would be most appropriate for handling each type of message or inbasket item. They made sure to have representation from each specific role in the practice when determining where certain messages could be routed.

Once the audit was complete, they started work on improving the inbasket. First they created team pools, with specific MAs, licensed practical nurses (LPNs) and registered nurses assigned to a particular provider. Next they selected a naming convention for the team pools. The standard name might consist of the clinic location and/or provider name. For example, Dr. Jerzak’s team pool is named “Jerzak Team.” This made it easier for individuals from an outside clinic to know the pool names. Typically, the MA/LPN for that provider’s team logs into the team pool inbasket and manages only that inbasket. In bigger clinics, each team consists of a larger team referred to as a pod. If a specific team within the pod is out on a particular day, the other MAs and LPNs within that pod can check the inbasket for the absent team pool. All messages now flow into the team pool inbasket. The only exception is the triage inbasket, which allows separation of the registered nurses’ (RNs’) work and the MA/LPNs’ work. Instead of having a triage nurse for each provider, the triage inbasket contains messages from all the providers within the larger “triage team” or pod. The team pool arrangement encourages members to work together to get the inbasket work completed in a timely manner. When time allows, the RN checks into team pools to help with the work.

The biggest challenge was determining what work should go to the team pool inbaskets and what work should go to the triage inbasket. In the past, the majority of messages, no matter what they were, ended up in the triage inbasket, making it difficult for the RN to see patients and complete the inbasket work. The team pool approach to inbasket work reduces the size of the triage inbasket and frees the RN to be more involved in direct patient care, such as diabetes education, blood pressure checks and Medicare wellness visits.

As with any process change, training individuals on the new process can be challenging. In the past, the RNs working triage received all symptom-based calls, handled the majority of results, and were the default contact for almost any issue that arose in the office. One of the first things discovered at Bellin is that it made more sense to have MAs or LPNs start handling some of those messages, especially those related to a recent office visit. Patients seemed to prefer to receive a call back from the MA/LPN who was in the room with the provider during their visit, since they had developed a relationship with that team member. This approach was definitely different, but providers caught on quickly to routing some results to the MA/LPN instead of always sending them to the RN. Being co-located helped make this process easier. For receptionists, Bellin developed standard messaging templates so that if a patient calls with a question, the receptionist is prompted to ask the patient if he or she was seen in the last two weeks. If the patient’s message does not require triage, the receptionist sends the message to the MA/LPN through the team pool inbasket instead of to the RN and the triage inbasket. In addition to being more efficient, this process increases patient satisfaction, as the patient knows the person who is communicating with them.

Many times, staff will flag messages as reminders or to let anyone working the inbasket know about something, e.g., a message was left with the patient to call the office or for the office to call once results are available. The receptionist also uses a red arrow, a functionality that is specific to EPIC, that indicates high priority messages that need to be addressed promptly by either the RN or MA/LPN. If a message in the inbasket does not need to be addressed until the following week, a reminder can be placed on the message so that it comes off the workload, and then automatically reappears as new on the specified date. These techniques help the team with time management and prioritization of the inbasket.

There are still some paper forms that come into the office, such as nursing home orders. For these forms, the receptionist drops it off in the RN paper inbasket and the RN enters it into the electronic health record (EHR) and routes it to the provider. For paperwork such as disability, FMLA or wellness statements that require the physician to complete and sign, each team member completes as much information on the form as they can to the level of their licensure before passing it on to the next person for completion. The receptionist fills in demographics and last office visit date before passing the form on to the MA/LPN. If the MA/LPN is unable to complete the form, it is passed to the RN to complete. The goal is for the provider to sign the complete or near-complete form, since the appropriate staff completes as much of the form as possible before it gets to the provider.

“Inbasket work also improves as your office visits improve because you’re addressing refills, referrals, scheduling follow-up appointments and documenting so your team can communicate effectively with patients if issues later arise. You are getting tomorrow’s work done today. It’s just way more efficient,” says Jami Burroughs, CMA.

Bellin is so satisfied with the new process that they are building on it. They are currently piloting a centralized refill team to handle all refill requests. They have also developed an anticoagulation clinic where either the pharmacist or trained RN handles INR results based on a protocol, eliminating the need to send those results to the provider’s inbasket. They are also using EHR smart phrases, such as “results reviewed at recent office visit,” to help streamline work.

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