EHR Inbox Stress: How to Cope
Types of messages
Problems of the inbox
Physician burnout
Strategies at the individual level
Group/system level strategies
Strategies from EHR vendors
Physicians spend several hours working with their electronic health record (EHR) system. Almost all medical practices have adopted this technology that promised to save time, reduce errors, and improve patients’ safety.
Despite the early promise, switching to EHRs has not been all good. This change in the health care workplace has been associated with reduced interaction between patient and provider, worsening of work-life balance, increased workplace stress, and physician burnout. The inbox or in basket is a significant contributor, although data entry, clerical work, and poor EHR design have all been held partially responsible for the negative effects.
The EHR Inbox
EHRs all have a messaging inbox as a component. This inbox receives messages from:
- Patient-initiated secure messages. These can be via the clinic’s patient portal, hospital website, or a mobile application.
- Administration/ management.
- Other physicians.
- Clinical staff.
- Results. From pathology, biochemistry, imaging, and others.
- Pharmacy.
- Other departments.
Messages pile up quickly, and the physician must deal with them. Hospitals often have rules about response times to patient messages. Some messages also impact patient care and must be answered promptly.
There are other messages which are shared for information purposes. These often do not contribute to patient care, but add to message burden.
On average, clinicians spend approximately one hour of a workday attending to their inbox.
Types of Inbox Messages
- Patient messages
- Laboratory and imaging results
- Requests (prescription refill approvals, order cosigns, patient call center requests, etc.)
- Administrative or informational.
Message Burden on Physicians
One study (Lieu) found that physicians in primary care received an average of 332 messages a week. The largest proportion (30%) were results from imaging, laboratory, and other tests. Patient-initiated messages comprised 22% of the messages received by physicians. Administrative and informational messages made up almost 20% of the messages.
The 332 messages resulted in 585 message views a week, as many messages needed multiple views.
Inbox work duration is a known measure of a practice’s efficiency. Health systems make systematic efforts to reduce the number of messages to physicians.
Attention Switching
The switching of attention between attending to the inbox, other EHR work (reviewing patient history, entering clinical details, or writing orders), and non-computer work happens dozens of times each working day. A higher number of messages is associated with a greater frequency of attention switching.
In other work fields, this is known to be associated with stress, inefficiency, and feelings of reduced productivity. Each task takes longer, and accuracy is lost. In medicine, we know that interruptions are associated with errors. Attending to more than one task at a time imposes a cognitive burden.
Patient Messages
Many medical systems enable patients to message their doctors securely through a portal; these messages reach the EHR inbox. The volume of such messages has been increasing. Many doctors feel they’re consulting two sets of patients, one physically and one virtually.
Hospitals and health systems usually have a time specification within which providers must answer patient messages. The volume of these messages, and the variety of demands on the physician, contribute significantly to stress.
Problems With the Inbox
The sheer volume of messages entering the inbox can be overwhelming. Many providers find their inbox impossible to manage during work hours. Most do log in from home to deal with a proportion of messages, reducing family and recreation time. One recent study found that primary care providers performed 37% of their inbox tasks outside work hours (Akbar).
The inbox is described as inexorable. Day and night, the messages keep coming, and the inbox keeps growing. Large numbers of unread messages lead to significant stress.
Some physicians have reduced their work to 70-80% of earlier levels to manage the increased demands of the EHR, especially the inbox.
Physician Burnout
Physician burnout is a significant problem facing healthcare. It is already at unfortunately high levels and seems to be increasing year on year.
Unfortunately, EHR implementation seems to have increased the incidence of physician burnout, particularly in the primary care area. Burnout has important consequences for patients, providers, and health care organizations.
Burnout among physicians is associated with increased patient dissatisfaction and reduced safety. Among health care personnel, burnout leads to depression, suicidal ideation, and other mental health problems. Organizations have to deal with personnel turnover; physician recruitment and replacement are expensive.
Individual Strategies
Faced with the inbox’s relentless nature, physicians have developed different strategies to keep on top of it.
Work from home. Whenever there’s a free moment, login and deal with some messages. This strategy is bad for work-life balance, but allows physicians to spend more of their work hours on patient care and interaction. Most physicians report dealing with their inbox outside work hours, but not many like doing it.
Open and done. Only open a message when you’re ready to deal with it. Replying to a patient message, adding a result to the patient’s chart, or taking action on an administrative message —do whatever is needed when you open messages. Putting it away for later, opening and reading the same message multiple times requires significant additional time. Besides, quick replies are more satisfying to patients.
Saved phrases and messages. Use software features to save phrases, instructions, and even entire guides and handouts. These can be sent as a reply or included in a message, with just a few keystrokes.
Patient education. Patients sometimes see the secure messaging feature as a chat application and expect back and forth messages in a short time. It is best to let them know that secure messages are not a form of conversation. Patients also get upset about delays in replies to what they see as serious problems. It is wise to let patients know that messaging is not appropriate for urgent matters (they should call instead).
Medical assistants. Many medical systems provide assistants to physicians who guide patients to examination rooms, make phone calls, etc. Such personnel can also be given access to the inbox after training. Issues with this strategy are the physician’s time required for training, competence, language issues, and turnover.
Pharmacists. Many routine refill requests can be simply passed on to pharmacists. They can check whether the patient has had laboratory tests, and whether a physician consultation is necessary. They also do a very good job of counseling patients about their medication.
Group or System Level Strategies
Reduce administrative and informative messages. A careful, regularly reviewed strategy is needed. The aim is to send as few messages from management. Results, transcripts, and other patient-oriented messages should only be copied to physicians who are directly involved.
Delegate. Some inbox tasks can be delegated to pharmacists, medical assistants, and other staff. Large medical groups and systems can develop and implement training programs to make this approach feasible.
Dedicated inbox time. Some time set aside during the workday to deal with the messages is very welcome. It reduces multitasking, attention-switching, and the need to save time from every patient consultation for the inbox.
Training. Physicians vary in the level of expertise with technology. Intermittent training on quicker ways to open charts, creating shortcuts, saving phrases and replies, and other efficiency measures can help physicians save time.
Inbox teams. Consisting of designated physicians, pharmacists, and assistants, these teams can cover for physicians on leave and help those overwhelmed by their inbox.
Knowledge transfer. Some physicians in a group manage their inbox efficiently. Their strategies and techniques can help others. These experts can educate others by didactic lectures and by making themselves available for a one-to-one consultation.
Eliminate clutter. Some messages create inbox clutter without impacting patient care. “Information only” messages often contribute nothing to the patient’s care. Similarly, several physicians may are sent the same results, although only one will take action. All personnel should be trained in need assessment of messages being sent or copied.
EHR Vendor Level Measures
Speech recognition technology. This has been around for a long time for general purpose use, but is still not considered accurate and dependable for health care use. EHR vendors and others should work on refining this technology to reduce the effort and time utilized in typing.
Artificial intelligence. This holds out tremendous hope for the future. Along with natural language processing, it could enable the EHR to listen to patients and physicians, extract relevant data and insert it in the appropriate sections, and even perform coding and billing tasks.
EHR redesign. EHRs need improvement of the workflow and user interface continually to keep up with changing needs. While some updates add features and capabilities, others improve usability and efficiency.
The inbox is not the same for everyone. The level of integration of the health system, the ease of use of the patient portal, and the composition of the patient population are important factors determining the burden of the inbox.
Not all physicians see it as a burden, either; some welcome the opportunity to build a relationship. Most providers, however, do see it as a drain on their time and a source of workplace stress. Whatever their attitude, all healthcare providers will benefit from adopting strategies to accomplish their inbox tasks in a streamlined and time-efficient manner.