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.
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)
Notifications of canceled appointments or no-shows for appointments with specialists
Any untriaged patient portal messages
Refill requests for medications that treat chronic conditions
Scanned copies of documents that are already signed
Automated (non-personalized) specialist correspondence for specialist visits
Progress notes on hospitalized patients
Logistical questions regarding tests, procedures, or appointments
Clarifying questions regarding a recent visit without first being directed to review their visit note
Questions about routine lab results
“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
“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.”
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
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.
EHR systems, by default, sort messages into certain types or categories, such as:
Care team and staff messages
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.
What's the best approach to creating these buckets?
Start by tracking the types of messages you're receiving in your inbox to get an idea of the volume. Examples of messages you could track include symptom-based calls, referral requests, refill requests, results requests, lab orders for future appointments, nursing home calls, medication questions, requests for appointments, etc. Keep a tally of the number of messages in each category; some types of messages are more common than others, which may differ by the physician.
Evidence suggests that messages from patients and lab results account for up to two-thirds of inbox work time for primary care physicians, so this may be a good place to start.2
Should test results go to the physician's inbox or the team pool inbox?
Where lab and imaging test results go may depend on the patient panel?regardless of pre-visit planning or pre-visit lab protocols being in place—and the physician's personal preference. However, you should not have results go to both inboxes because the actions someone takes in one inbox may not be reflected in the other. If it makes the most sense in your practice for results to go to the physician's inbox, make sure that the members of the team pool can check into it and that specific workflows are in place for managing results when necessary.
How does this apply to my paper inbox?
The paper inbox can be sorted and managed in much the same way as the electronic inbox, with a non-physician team member triaging and managing the majority of items. Much of the paper inbox are forms and prior authorizations. Each team member should complete as much of the form as they are able, based on their role and training, before sending it on.
For example, you may see an influx of school forms at the end of summer. In a sample scenario, the front desk or patient services representative (PSR) could fill out demographics and dates of visit on the form, and the medical assistant (MA) or licensed practical nurse (LPN) could fill in the rest, involving the registered nurse (RN) if needed. The form should be complete or almost complete before coming to the physician for review and signature. Once signed, the form could be routed back to the PSR to be scanned into the record for future reference and then sent to the patient. For organizations that scan all paper forms into the computer, the responsible team member can complete the task and have it scanned into the EHR upon completion.
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.
How many people should be part of a team pool?
One possible composition for a team pool would be the MA and/or LPNs working with the physician, an RN, and a PSR. Adapt the number of people and composition of the team pool to fit your unique practice setting.
How does a team pool help with vacation coverage?
A team pool with access to the physician's inbox allows for ongoing management while the physician is away and prevents the accumulation of work that must wait until the physician returns. Anyone on the team pool can check in and help prioritize the few items that need physician attention and route those to the covering physician. Consider establishing protocols for common inbox tasks that do not require your review and signature. With these processes and protocols in place, the MA or LPN should be able to continue to work on routine tasks such as normal test results and refills while you are gone.
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.
How do I know that my team responds to messages and addresses questions?
Ask that your team insert flags to denote that something needs follow-up, needs a signature, or was completed. If your practice uses Epic®, you can ask that they mark a task "done" when completed, which removes it from view but doesn't delete it. Marking an item "done" keeps the inbox clean.
Conversely, suppose a team member opens a message but finds that it is too complex to address at that moment. In this scenario, the team member should mark that message “new” or “unread” so that other team members do not assume it was already handled.
How frequently should a team pool member check the inbox for results?
Time management is extremely important for effective inbox management.
For example, at Bellin Health in Green Bay, WI, the most efficient MAs and LPNs learn to check the inbox continuously during the day. They make every minute count, such as handling a quick refill request in the brief time they may have between patients. For normal lab results, the team member can notify the patient via phone, patient portal, or letter, then mark the task "done" in the inbox in these short windows of time. A single RN at Bellin oversees the inbox for 3 or 4 providers; she checks into the pool at least every half day. RNs and LPNs comprise the core team at Medical Associates Clinic in Dubuque, IA. In that clinic, the nurses check the inbox continuously during the day, and then once or twice per day they verbally address any messages with the physician that will require input.
Do patient services representatives (PSRs) have the proper training to assist with inbox management?
Yes, PSRs can assist with some tasks. Create a template for PSRs to follow so that they know how to respond when they receive certain requests. For example, before inbox optimization, a patient who called with a medication question might have been directed to the triage nurse. The triage nurse would need to look up the patient, medication, and physician's orders before returning the patient's call. As part of inbox optimization, the PSR would use the template to identify and route the call to the MA/LPN attached to the patient's doctor. Because this MA/LPN has a personal relationship with the patient and is familiar with the physician's orders, she can answer the question more quickly.
Alternatively, the MA, LPN, or RN can route particular messages to the front desk staff, so they don't need to tap into the inbox directly. Examples include asking the PSRs to complete basic nonclinical information in forms, such as the practice address, physician's name, unique physician identification number (UPIN), date of the last visit, and any upcoming visits and associated labs. If you are implementing a pre-registration process, you may wish to consider having new patient coordinators fulfill some of these inbox management duties when they are not registering new patients.
What role can an advanced practice clinician (APC) play in inbox management?
In some organizations, the APC role structure means they spend roughly half of their time on direct patient care, and half the time is devoted to inbox management and other deskwork support for the practice. In these models, the APC manages most messages in the physician's inbox, bringing any situations requiring additional expertise to the physician.
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.
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).
I'm inundated with messages from skilled nursing facilities (SNFs). Is there a special technique for managing these?
The volume of calls from these facilities can be overwhelming. It can also be confusing if tests ordered by your SNF team flow to both their inbox and yours. How to handle them depends on your practice's approach toward these patients.
If you are working with advanced practice clinicians to manage patients in nursing homes or SNFs, it is most efficient to have test results and other messages go to the APCs instead of your inbox.
If you have no particular program for helping SNF patients, then work with these facilities to develop standing orders that will decrease the number of calls they need to make. Communicate that your triage nurses are empowered to answer many of the questions from SNFs per protocol. Encourage SNFs to make all non-emergency calls during office hours and work with the SNF staff to batch their communications so that they make only 1 or 2 contacts a day. Be sure to order lab tests that may need follow-up, such as routine INRs or electrolyte tests, early in the week. This avoids contacting the doctor on call—who may not know the patient as well as your team—during the weekend.
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.
The majority of inbox messages do not require “physician eyes”, and the ones that do should be triaged prior to being sent to the physician
Physical co-location or brief huddles between team members and physicians can eliminate unnecessary back-and-forth message exchanges.
Instead of setting aside time, encourage team members to use any free moments to check the EHR inbox. For example, longer appointments may give team members who aren't part of the visit a 10- to 15-minute window to check the EHR inbox throughout the day.
These Success Stories provide examples of how others have successfully overcome inbox challenges:
Leverage Standing Orders and Protocols to Ease In-Basket Burdens
Teamwork Tames the Inbox
Restructuring EHR In-baskets in Minneapolis
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
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