Based on an American Medical Association news article published May 2, 2019 and Sara Berg's interview with Brad Wozney, MD, family physician, Bellin Health, Green Bay, WI and Thomas Sinsky, MD, retired internist.
Learn how an empowered team working together can reduce in-basket burden for physicians.
The default destination for most communication in the physician office is a doctor's in-basket, housing overwhelming numbers of items and folders. As the workload grows, so does the volume of the in-basket, creating a burden that is difficult to effectively manage throughout the day. This leads to extra hours before and after clinic to complete between-visit clerical work, adding to physician burnout symptoms.
“What's really the problem? Those of us that are clinicians that have in-baskets, we know that we get overwhelmed with the amount of stuff and it just comes to us,” family physician Brad Wozney, MD, said during a presentation at the Team-Based Care Training Camp held by the AMA and Bellin Health.
Between-visit work is more than just the electronic health record (EHR). It includes receiving, sorting, organizing, and responding to all information flowing into the practice from email, phone calls, faxes, postal mail, forms, and the EHR. It is the unclear or undefined workflows that add to the dreaded pajama time, which means physicians need to trust their teams to help balance their workload.
Developing the Intervention
“We need to empower our staff. If we don't give them the opportunity to help us out, they're not going to do that,” said Dr Wozney of Bellin Health. “As a clinician, I have to trust that my staff is doing what they're supposed to and some of that is giving up control.”
Teamwork can help tame the in-basket and reduce time physicians spend on administrative tasks (Figure 1).
Reorganize and reroute
Physicians should work with IT to review and consolidate extra folders. Reroute tasks to appropriate team members to free up time for the physician to spend with the patient.
“Eliminate stuff I don't need to see,” Dr Wozney said. “If I don't need to see it, don't send it to me.”
For example, if someone is looking for an immunization record, the physician does not need to see it—just give it to the patient. The same goes for hospital progress notes, nurse visit notes, physical therapy notes, hospital test results, and pre-visit labs. That information doesn't end up in Dr Wozney's in-basket unless something needs his attention.
Tackle between-visit work
“On any given day when we see 25 to 30 patients at our clinic, we might have another 100 non-face-to-face encounters,” said Thomas Sinsky, MD, an internist. “These include lab reports, emergency room notes, consultations, hospital discharge notes, lots of phone calls, emails, faxes, and forms to be completed. So, we are actually serving 130 patients a day.”
“This steady stream of incoming information must be received, sorted, organized, and communicated. This volume of work requires a finely tuned, highly organized team. In our model, almost all of this important, complex, personalized work between visits is performed by the nurses.”
—Thomas Sinsky, MD
To accomplish this, Dr Sinsky's office used 3:1 staffing—3 nurses and 1 physician. One nurse will mostly manage the phone calls, mail, faxes, EHR in-basket, and form completion.
While the other 3 nurses primarily manage face-to-face patient visits, everyone is cross-trained. Then, during buffer time—an hour before or an hour after clinic—the team organizes information for upcoming visits, makes Medicare post-hospitalization phone calls, and completes other between-visit work that was not accomplished during patient visit hours.
“This ratio of 3:1 allowed us to keep the clinic visits running smoothly while still keeping up with the information and communication that pours into the clinic throughout the day,” he said.
Another important strategy involves engineering a large amount of in-basket and between-visit work out of the system. Most results reporting can be eliminated by pre-visit lab testing, and most prescription work can be eliminated by annual synchronized prescription management.