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Restructuring EHR In-baskets in Minneapolis – St. Paul, MN: A Case Study

At HealthPartners Medical Group, inbasket management was initially tackled as part of a larger quality improvement effort that coincided with a system-wide rollout of EPIC in 2004. A group of local leaders, providers and staff, supported by informatics experts, worked to standardize workflows, including inbasket management. The standardized workflows combined evidence-based medicine and practice efficiencies and became known as the Care Model Process. After the introduction of the new workflows, both patients and providers noticed that communication could be further improved, particularly follow-up after patient phone calls, which clinics tracked through the electronic health record (EHR) inbasket. Results from the organization’s American Medical Group Association (AMGA) satisfaction survey in 2006 showed that providers wanted even more standardization to be applied to the inbasket work. A quality improvement pilot to further standardize inbasket management was initiated in primary care settings and then extended to all medical and surgical specialty groups at HealthPartners. The success of this effort was captured in the results of the 2016 AMGA survey, in which providers reported that eliminating inbasket inefficiencies decreased the burden of work and increased satisfaction in the practice.

In the HealthPartners quality improvement project, the inbaskets themselves and the way they were managed were completely restructured. To ensure that everyone on the team could contribute to appropriate and timely follow-up, “blinded” inbaskets for physicians were eliminated. Instead, the physician’s rooming support team for the day are responsible for checking into that physician’s inbasket. Each team member is responsible for reviewing, responding or routing messages as appropriate. This approach has been helpful for managing patient messages and prepping those items for the clinician so messages no longer bounce back and forth between team members.

Folders within the inbasket were consolidated, reorganized and standardized.

  • A “for information only” category was created to filter consult notes and notifications of hospital discharge that did not require immediate attention.

  • “Action needed” items, such as test results and questions from patients, went to another folder and could be flagged to draw the physician’s attention.

The reception staff use standard messages, specific lines of questioning and smartphrases to make sure that all fielded calls are placed in the correct folders for the care team. Specific types of information are placed into an encounter to prepare it for the clinician and appropriate concerns are converted to a phone visit. This approach has been particularly useful for vetting test results, messages that should be sent directly to the physician, and symptom-based calls for the registered nurse (RN).

The RN is the only team member who still has a separate inbasket. When the revised team inbasket workflow was piloted in three clinics, they discovered that having the RN check into the same inbasket with the rest of the care team was very inefficient. There were too many “touches” by multiple team members and it was difficult to see when tasks were completed. With one word or phrase entered by reception, calls about symptoms are routed immediately to the RN inbasket.

“The AMGA survey showed that our physicians wanted to see specific aspects of the inbasket streamlined: medication refills and test results,” said Joan Flaaten, RN, Director of the Care Model Process. “Now about 95 percent of lab test results are released to patients automatically within four hours via the patient web portal. Patients appreciate this speed because it means that if they have questions, they can call in and get answers while the encounter is still fresh in everyone’s mind. In addition, this approach ultimately reduced the number of calls we received from patients who were wondering where their test results were and when they’d receive them.”

There was some initial resistance to having results available so quickly to patients because physicians worried they wouldn’t have time to review the results before release. HealthPartners developed a test result guide to train staff on varying degrees of abnormality in test results so they could accurately flag those that warranted a phone call from the physician. The test result guide explains what is a normal, minimally abnormal or clinically abnormal result for several common tests. For example, Lyme disease and hepatitis testing are included in this guide, which allows team members to prepare patients in the exam room in the event their results come back abnormal. For clinically significant results, patients are contacted directly by the care team to enable follow-up. Reporting test results to patients can also be delayed in some circumstances. For example, CT scans, MRI results and pathology findings are often manually released because they require interpretation from a physician.

Patients who prefer to receive test results by phone or letter are notified by their chosen method.

HealthPartners also took a unique approach to simplifying the paper inbasket. Several clinics established a goal to reduce paperwork by 15 to 20 percent. They were consistently finding that everything in paper form ended up in one spot on the physician’s desk. This made it hard to prioritize important documents amidst a single pile of paper. Over a one-month period, clinic staff collected every piece of paper routed to the physicians and scanned it in so it could be tracked. Some of these scans, such as FMLA forms, were added to the EHR or patients’ medical records so they could easily be pulled up in the future and fields would already be completed. They found that the best approach was to give physicians three baskets for scanned paper forms: read, priority and outbox. This clear demarcation between scanned paperwork that is important vs. less important eased the paperwork burden for busy physicians.

Training team members to direct messages to the appropriate paper or electronic folders, as well as being clear about their roles in managing the inbasket, is critical for success and sustainability. New hires at all levels are trained on the inbasket workflow during orientation. The expectations are clearly defined and local supervisors understand their team’s responsibilities regarding the inbasket.

“Inbasket management is not plug and play. Figure out your best team, work with them to design the management approach, pilot it and then finally spread it to others,” said Beth Averbeck, MD, Senior Medical Director of Primary Care. “That’s what worked at our organization because our team care model is a living, breathing organism — we were embedding the philosophy and supporting the work locally.”

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