How Kaiser Permanente Southern California Permanente Medical Group (SCPMG) developed a novel approach to inbox management for primary care physicians.
Primary care physicians were spending on average 6-10 uncompensated hours per week addressing items in their inbox. This work included:
Following up on patient lab results,
Answering messages and phone calls from patients,
Refilling prescriptions, and
Handling messages from specialists, physical therapists, pharmacists, case managers, and other staff.
The majority of this work did not need a specific physician to address it and could be standardized and handled by staff who were following protocols.
Developing the Intervention
The Cudahy Medical Office Building at the Downey Medical Center in Southeast Los Angeles began a novel approach to inbox management with a team of 10 full-time physicians, 2 licensed vocational nurses (LVNs), and 2 message management nurses (RNs). Most physicians practiced adult primary care in both Family Medicine and Internal Medicine and worked full-time with panels of more than 2000 patients. A typical physician saw 20-25 patients daily in addition to scheduled telephone and video visits.
The crux of the intervention was the designation of an “inboxologist”: a physician who is responsible for covering all 10 physicians' inboxes over a 24-hour period (5pm - 5pm) from Tuesday through Friday. The inboxologist may or may not be one of those 10 physicians. A corresponding set of standardized, evidence-based protocols were developed to guide the inboxologist's work. Using these protocols, all actionable items (except for controlled substance refills and FYIs) are handled by the inboxologist instead of the other physicians who have “surrendered” their inboxes.
The inboxologist was not the initial triage point for messages—all inbox messages were first reviewed by message management RNs extensively trained to assess message urgency, triage patient requests, and pend orders and refills. Message management RNs might call the patient for further clarification or pull needed information before sending the message to the inboxologist. They may make the decision to schedule an urgent appointment or video visit or send the patient to the ER. The majority of inbox messages (at least 65%) could be addressed by someone other than the inboxologist or treating physician.
The expectation was for the inboxologist to address the inbox at 8am, the start of the working day, and empty the inbox by 5pm. Since the inboxologist was responsible for all inbox items from 5pm the day prior, some chose to get a head start on to managing the inbox the night before, or in the early morning hours before 8am. The inboxologist assigned to Monday handled messages for the 72-hour period from Friday at 5pm to Monday at 5pm, and this individual was compensated accordingly.
The designated inboxologist worked with 2 dedicated LVNs. While the LVNs were always on site, the inboxologist had the opportunity to work from home. This allowed for a great deal of focus and efficiency and was desirable for those who have long commutes. It also helped free up office space.
Patients were all preemptively informed of this team-based approach to managing their needs outside of the office, telephone, or video visits.
Some physicians were concerned that they would lose touch with their patients or not be fully managing their patients when others followed up on their results. To mitigate this possibility, it was important to obtain a consensus among all providers in the group about what inbox items could be standardized based on current medical practice. Kaiser Permanente developed protocols that gave the inboxologist collated information and pre-scripted phrases with instructions for the staff.
For example, some lab abnormalities were common and straightforward enough to be handled by the inboxologist without forwarding to the primary provider, such as hypokalemia, mild anemia, positive h. pylori, prediabetes, and hyperlipidemia. When the primary provider saw the patient down the road, he or she would see those results at that time, which preserved continuity of care. For any abnormalities outside of this scope, appropriate follow-up was arranged with the primary provider, either in person or via a telephone or video visit.
Some providers were concerned that their patients may not want another physician instructing them or following up on their results. However, it was found that by simply telling patients in advance that messages and labs may be seen or handled by other physicians, it became a non-issue. Patients were simply happy to get results and responses in a timely fashion.
Finally, all of the providers in the group had a secure text messaging system on their work phones that was used daily—sending messages to the group if something came up, if the covering provider was not sure what to do, if the provider wanted feedback, etc. This system helped to keep everyone on the same page about their patients' latest developments.
Physicians who surrendered their inboxes saw one extra patient per half day, which offset the cost of the inboxologist. Despite these extra 2 appointments per day, most participating physicians were able to finish their work 1-2 hours earlier each day because they were not burdened by their inbox. As a result, physician morale scores improved.
“I really enjoy the flexibility. I enjoy a cup of coffee at home as I work through the messages at my kitchen table. Though I am busy during the day handling the inbox, I can take an hour if needed to take my kids to school, or get in a workout”
—Dr Erica Romblom
Other positive results thus far include:
A reduction in the number of tests ordered by physicians
With the goal of only ordering tests that are supported by evidence-based medicine, physicians would pause to consider the necessity of each test since they knew their colleagues would see what they order. For example, not everyone needs a CBC or lipid panel every year.
A reduction in patient messages due to expedient handling, and improved patient satisfaction
Often if patients don't get a response in 2-3 days (or sometimes sooner) they tend to call or message again about the same issue. Or if they see an abnormal flag for a result on their patient portal and have not heard anything from a physician, they get worried and send a message. These extra patient messages can all be avoided by having an inboxologist get to messages and results on the same day.
An improvement in work-life balance for physicians
By allowing physicians to participate in more direct patient care and eliminating the monotonous, clerical, and time-consuming nature of the inbox, the inboxologist program has made it possible for physicians to regain meaning and purpose in their careers. The improved work-life balance led to better rested, more mentally-focused physicians with improved practice sustainability.
Kaiser Permanente is a large health care organization with 8 regions across the United States. KP Southern California, one of the largest regions, is powered by Southern California Permanente Medical Group (SCPMG), a separate entity with more than 9750 physicians across 268 medical office buildings and 13 medical centers.