Team-Based Management of High-Priority In-Basket Messages

THE INNOVATION

A great contributor to primary care physician (PCP) burnout is the inability to “unplug” from the electronic health record (EHR) for fear that urgent patient messages may be missed.¹ If a PCP is not checking the EHR regularly, urgent patient concerns may go unanswered for more than 24 hours, leading to adverse outcomes and patient dissatisfaction.² To mitigate this problem, we created a team-based, rotating in-basket management system.

WHO & WHERE

The clinical team involved in this innovation consists of 4 PCPs, team nurses, medical assistants, and other clinic staff involved in synchronous and asynchronous care of an estimated 3,568 patients. We are 1 of 4 teams in a larger family medicine clinic using Epic (Epic Systems Corp) as its EHR.

HOW

High-priority in-basket management is designed as a workflow change at the physician level. This workflow can be adapted for smaller or larger teams. Each physician “attaches” themselves to the in-baskets of their fellow physicians, like how time off coverage is typically designed. The physicians then follow a rotating weekday schedule so the responsibility of addressing each other’s urgent messages is shared equally.

To reduce burden on the high-priority physician, we agreed on a narrow set of in-basket categories requiring same-day attention: high-priority patient call encounters, high-priority patient portal messages, and medication refill requests. The responsibility of the high-priority physician is to triage and manage in-basket messages meeting those criteria for the other team members. This could mean a same-day response to the patient, or simply leaving the message for the intended PCP if the issue is determined to be non-urgent. If the former, the high-priority physician lets the PCP know how the messages were managed in the “follow-up” comments section of the EHR, and then the high-priority encounter is left in the PCP’s in-basket as a FYI.

LEARNING

A post-implementation survey revealed that all 4 team physicians agreed participating in this pilot reduced their feelings of burnout. By narrowing the scope of responsibility for the high-priority physician, the estimated added workload on assigned days was low, though responses varied. The 4 involved physicians estimated they spent as few as 10 and no more than 50 minutes on high-priority message management on their assigned days (Supplemental Table). Current practice for most ambulatory care physicians requires them to solely manage their own in-basket every day, including urgent patient needs, and this makes it difficult for physicians to ever disconnect from patient care. These data reveal that simply distributing this responsibility among team physicians can have a meaningful impact on burnout. Although this innovation was piloted in a group of 4 PCPs, it could be adapted to clinical teams of any size or specialty. Implementation simply requires teams to identify “high-priority” in-basket messages, then design a rotation schedule.