How Will This Toolkit Help Me?
Learning Objectives
Implement standard workflows for message routing and common inbox tasks
Decide which team members should be responsible for various inbox tasks
Create filters to separate inbox signal from noise
The EHR inbox is the default destination for most forms of communication in outpatient clinic settings. As the physician's workload grows, so does the volume of the inbox, creating a burden that is impossible to manage alone. Often, physicians face spending long hours before and after clinic to complete "between visit" clerical work.1,2 For some, this can add up to an extra 1 to 2 hours of work every day and is a major contributor to physician burnout.1,2 One study of primary care physicians found that high numbers of inbox messages required physicians to more often switch their attention between other work and processing EHR messages—adding to the time it took them to complete their inbox work.3
The reality is that (1) many inbox messages do not need to enter the inbox in the first place, and (2) of those messages that should enter the inbox, the majority do not need to be routed to the physician.
This toolkit will help you keep unnecessary messages from being routed to your inbox in the first place, guide you through establishing a centralized team inbox, and provide workflows to empower team members to contribute in a meaningful way to inbox management.
Table 1. Things That Should Not Enter the EHR Inbox
THE PHYSICIAN INBOX |
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WHAT | HOW TO SOLVE THE PROBLEM |
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Results of tests not ordered by the physician Notifications of canceled orders or overdue (expiring) orders Notifications of scheduled appointments Patient Event Notifications which are not federally required (eg, admissions to hospital outpatient departments, colonoscopies, pharmacy visits, other ambulatory visits)
| Turn off automatic notifications for physicians. Can also consider batched notifications. |
| Institute system-wide patient outreach protocol for canceled/missed appointments originating from the department where the appointment was scheduled to take place. |
| Use a patient portal protocol for triaging messages. |
| Implement a refill protocol with standing orders (as allowed by state regulation). |
Scanned copies of documents that are already signed Automated (non-personalized) specialist correspondence for specialist visits Progress notes on hospitalized patients
| Turn off automatic carbon copy (cc) function. |
THE CARE TEAM INBOX |
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WHAT | HOW TO SOLVE THE PROBLEM |
---|
| Reroute to clerical or administrative inbox. |
| Optimize communication with patients via after-visit summaries and shared visit notes with patients. Make the note easily accessible to patients on the patient portal. |
| Reroute to billing department. |
| Implement pre-visit planning with pre-visit labs. Consider adding FAQs about routine results as a smart phrase. |

At Bellin Health, we've worked hard to redistribute inbox workloads. An effectively managed inbox 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 inbox management efficient, and this team approach ultimately leads to better, more timely patient care.”
—James Jerzak, MD; Bellin Health
Five STEPS to Optimize Your EHR Inbox
Engage the IT Department
Group Different Types of Messages Into Common Buckets
Create Team Pools Corresponding to Each Bucket of Messages
Assign Team Members to Cover Team Pools
Develop Workflows and Train Team Members to Manage Team Pools
STEP 1 Engage the IT Department
Quiz Ref IDInformation technology (IT) support is essential for establishing and maintaining a manageable inbox. As seen in Table 1 above, your IT team can help configure your EHR to decrease the number of items that enter your inbox. The best way to tame the EHR inbox is to prevent unnecessary messages from entering the inbox in the first place.
It is also essential to get rid of old messages. An excessive volume of old messages in inboxes can slow down the speed of the entire EHR.
You may also consider working with IT to:
Consolidate folders to decrease the number of different categories in your inbox
Incorporate flags or checkboxes to help prioritize or route messages that need a particular team member's prompt attention.
Develop a system that would allow team members to mark a message for follow-up on a future date, then divert that message to a holding pen folder. The message would be re-sent to the inbox on the specified date and appear as a new message. Many EHRs make it possible to delay sending a message, and this capability improves follow-up care.
Develop "smartphrases" that team members can use as shortcuts for responding to items in the inbox, such as normal lab results.
STEP 2 Group Different Types of Messages Into Common Buckets
EHR systems, by default, sort messages into certain types or categories, such as:
Care team and staff messages
Phone calls
Refill requests
Results
Patient portal messages
Media (eg, faxes scanned into the chart)
CC'd notes, charts, or other notifications
Physicians need direct access to some message types, such as test results and staff messages (direct personalized messages to physicians from team members or other physicians).
Other message types (cc'd notes, charts, or other notifications) consist primarily of unnecessary information (noise) that does not need to enter the inbox at all, and you should work with IT to remove them from the inbox (refer back to Table 1 for examples).
The remaining message types (phone calls, patient portal messages, faxes, refill requests) should be grouped into common buckets to determine how they should be addressed and by whom (Figure 1). This will, of course, vary by your practice setting and patient population.
STEP 3 Create Team Pools Corresponding to Each Bucket of Messages
Quiz Ref IDAfter gathering information on the categories of messages entering the inbox, meet with representatives from all staffing roles and IT to evaluate routing. Determine if you could implement a more efficient system for routing messages that better utilizes the entire team to the top of their skill sets. Create new team "pools" that correspond to each category; this pool will be where all messages falling into that category will be routed (Figure 2).
Quiz Ref IDIn a team pool structure, it is ideal for each physician or advanced practice provider (APPs) to have their core team of MAs, LPNs, and/or RNs who are always assigned to the pool. This consistency allows everyone to be familiar with the physician's patients and their care plans. It also decreases the chance that multiple care team members are checking the same pools and doing duplicative work or, on the flip side, messages fall through the cracks because no one knows they haven't been addressed or completed.
With this approach, the first touch on any message aside from direct personalized messages from other staff members or physicians is by a non-physician team member. Of course, any messages that require physician attention can be rerouted directly to the physician's inbox, or a team pool member can verbally notify the physician that something needs immediate attention.
Workforce shortages can complicate the team pool approach to inbox management. Therefore, it is essential to make team members feel comfortable asking physicians questions, especially when they are covering for a physician they do not typically work with. Constant communication between physicians and other team members is key.
STEP 4 Assign Team Members to Cover Team Pools
Empowering and trusting other members of the care team, encouraging critical thinking, and always putting the patient's needs first are team-based care principles that support efficient inbox work. In general, the core concepts for successful team-based care apply directly to inbox management.
Again, the overarching principle is that physicians should not be the first set of eyes on most messages. Clinical team members (triage RNs, MAs, APCs) can address clinical questions, and nonclinical team members such as patient liaisons, PSRs, billing staff, etc., can address nonclinical questions. Figure 3 illustrates a sample workflow for first touches for different types of inbox messages.
Here are some additional team-based care principles that can contribute to your success:
Co-locate team members. 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 inbox. It may seem counterintuitive, but in-person communication is crucial for effective inbox management. Consider co-locating team members such as triage nurses, rooming team members, and schedulers to 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.
Use verbal messaging rather than electronic messaging whenever possible. Verbal messaging is more efficient and is a richer form of communication. Co-location supports verbal messaging, but this can be the predominant form of communication in any setting.
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.
STEP 5 Develop Workflows and Train Team Members to Manage Pools
Creating standardized and simplified workflows and training team members on using them will help everyone on the team perform more efficiently.
Quiz Ref IDFigures 4, 5, and 6 are examples of workflows for managing patient calls, patient portal messages, and form requests.
Access Sample Intake Processes for Telephone and Refill Encounters.
Other areas to develop:
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. Add a pharmacist to your team to help maximize the use of generic medications (and subsequently minimize the need for prior authorizations) and ensure the patient is adhering to their current medications before adding or escalating therapy.
Implement standard refill protocols.Refilling all long-term medications for the maximum allowed by state law (90-day supply with 4 refills, or "90x4") will markedly decrease the volume of refill requests. In many states, this maximum refill period ranges from 12 to 15 months. Consider an automated refill request system or a centralized refill team for refill requests that still come through. The refill team may be the same team that handles prior authorization requests.
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 inbox tasks related to these patients could be valuable.
Anticipate the needs of complex patients. A robust transitional care program for complex patients leaving a hospital or skilled nursing facility could avert complications. Anticipating and meeting their needs before a crisis may, in turn, decrease inbox work and phone calls to the office.
Start using pre-visit laboratory testing. Pre-visit labs rely on scheduling labs for the next appointment before the patient leaves so that the office can review and send results in advance of the next visit. With protocols in place, empowered team members can perform a preliminary review and flag abnormal ones to save time for the physician. For abnormal results, there should be a protocol in place to communicate these results to either the triage RN or the physician. Most abnormal results can wait to be discussed until the day of the scheduled visit, but if something requires sooner attention, the team can contact the patient with additional instructions.
Empower team members with autonomy. Empowering team members to make decisions and take on additional tasks is a valuable technique for cutting down on messaging. Professional development programming can help your team members perform to the top of their licenses. Creating protocols is also very helpful, with the caveat that the protocol is not the bottom line—always communicate and ask about “out of protocol” cases as a learning opportunity.
For more information, please review the AMA STEPS Forward® Taming the EHR Playbook (PDF).
Managing the inbox should not rest solely on the physician. There are many ways to reduce the amount of time spent on this task (Figure 7). Leverage the skills of the care team to apply the principles and workflows of team-based care to be more efficient, redistribute the inbox workload, and ultimately get more done during the clinic day.
Access Inbox Buckets and Team Pool Assignments Visual.
Journal Articles and Other Publications*
Winner J. Practical ways to manage your EHR inbox. Fam Pract Manag. 2021;28(4):27-30. https://www.aafp.org/link_out?pmid=34254765
Arndt BG, Beasley JW, Watkinson MD, et al. Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations. Ann Fam Med. 2017;15(5):419-426. doi:10.1370/afm.2121
Murphy DR, Satterly T, Giardina TD, Sittig DF, Singh H. Practicing clinicians' recommendations to reduce burden from the electronic health record inbox: a mixed-methods study. J Gen Intern Med. 2019;34(9):1825-1832. doi:10.1007/s11606-019-05112-5
Murphy DR, Giardina TD, Satterly T, Sittig DF, Singh H. An exploration of barriers, facilitators, and suggestions for improving electronic health record inbox-related usability: a qualitative analysis. JAMA Netw Open. 2019;2(10):e1912638. doi:10.1001/jamanetworkopen.2019.12638
Shanafelt TD, Dyrbye LN, Sinsky C, et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016;91(7):836-848. doi:10.1016/j.mayocp.2016.05.007
Eaton P. Managing messages. Fam Pract Manag. 2012;19(5):25-29. https://www.aafp.org/link_out?pmid=22991907
Tran B, Lenhart A, Ross R, Dorr DA. Burnout and EHR use among academic primary care physicians with varied clinical workloads. AMIA Jt Summits Transl Sci Proc. 2019;2019:136-144. eCollection 2019. https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/31258965/
Melnick ER, Fong A, Nath B, et al. Analysis of electronic health record use and clinical productivity and their association with physician turnover. JAMA Netw Open. 2021;4(10):e2128790. doi:10.1001/jamanetworkopen.2021.28790
Yan Q, Jiang Z, Harbin Z, Tolbert PH, Davies MG. Exploring the relationship between electronic health records and provider burnout: a systematic review. J Am Med Inform Assoc. 2021;28(5):1009-1021. doi:10.1093/jamia/ocab009