9 steps to reduce the EHR inbox—and stress—at the system level

Tanya Albert Henry , Contributing News Writer

AMA News Wire

9 steps to reduce the EHR inbox—and stress—at the system level

Sep 23, 2023

UCHealth in Colorado only allows a test result to go to one physician or nonphysician provider so there’s no confusion over who will handle it.

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Boston’s Atrius Health automated prescription renewals—setting up a protocol that doesn’t require a primary care physician to sign each approved medication reauthorization—to reduce the inbox volume of renewals by 50% for physicians. Before the change, prescription renewal requests comprised 16% of the total inbox message volume, which was about 16 requests per physician daily.

And Medical Associates Clinic in Dubuque, Iowa, empowered nurses to manage the inbox. Each nurse is paired with a physician to develop a close working relationship, allowing them to address medical advice requests within their scope, renew medications by protocol, perform the first review of laboratory results and more.

These are just a few of the concrete examples that are provided as part of the AMA Steps Forward® resource “A System-Level Approach to EHR Inbox Reduction” (PDF). The nine-step process offers guidance for reducing and streamlining the inbox to ease the burden on doctors, one of the stressors that contribute to physician burnout.

“We used a strategy of elimination, automation, delegation and collaboration to find a multitude of tactics to reduce the total volume [of messages]. We really understood that there was no one single fantastic solution that would solve it all and that we had to tackle this piece by piece to get the results we wanted,”  Jane F. Fogg, MD, MPH, health care executive and former executive chair of internal medicine and family medicine at Atrius Health, said in a webinar focused on this topic. Her organization reduced their in-basket volume by 25% between 2016 and 2022.

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Dr. Fogg is a co-author of the EHR inbox-reduction resource with CT Lin, MD, chief medical information officer at UCHealth, and Christine A. Sinsky, MD, the AMA’s vice president of professional satisfaction.

Reducing physician burnout is a critical component of the AMA Recovery Plan for America’s Physicians.

Far too many American physicians experience burnout. That's why the AMA develops resources that prioritize well-being and highlight workflow changes so physicians can focus on what matters—patient care.

Here are nine steps that can help your organization reduce inbox messages.

Organizations should start measuring their current state by quantifying the type and volume of inbox messages. This can help you understand where the greatest opportunities are for improvement. The EHR audit-log data—such as Epic’s Signal data or Oracle Cerner’s Lights On Program—can help quantify the number and type of inbox messages each specialty receives weekly.

Next, develop a governance structure, strategic framework and a target for inbox reduction. Because inbox management is an ongoing improvement opportunity, it is important to not rush the process. Preliminary optimization can take up to a year and the organization will continue to refine efforts going forward.

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A lot of what is in the inbox doesn’t have to be there. Discontinue the carbon copy, a strategy known as “d/c the cc.” Many other messages don’t contain useful information and can contribute to physicians missing important messages. Eliminate the unnecessary messages at the system level before they hit the inbox and route important messages to folders that physicians look at.

To significantly reduce inbox messages, implement pre-visit lab testing and “90 x 4 call me no more” prescription-renewal protocols. Having lab results at the visit allows patients to ask questions in person. Meanwhile, an annual renewal protocol eliminates most patient refill requests outside of visits and reduces unnecessary gaps in patient access to their medications.

This is a strategy captured in the phrase “you order it, you own it.” Establishing a single recipient for test results helps organizations avoid the safety hazards associated with ambiguity about test result follow-up.

It reduces the possibility that multiple physicians or other health professionals believe that someone else is responsible for following up on a result. When that happens, meaningful results can fall through the cracks. And it can also help to reduce the volume of test results in non-ordering physicians’ inboxes.

It is federally mandated to automatically release results to patients. By sending normal results directly to the patient portal, you can bypass the physician’s inbox and safely reduce the burden. Abnormal results should still be routed to the ordering care team in addition to the patient.

Physicians can still request, by exception, that specific test results be forwarded to their inbox, whether normal or not.

Develop protocols so that a prescription renewal team, automated technology or an empowered care team member—such as a medical assistant or nurse—can handle prescription renewal requests. This means creating standards for the types of medications that a team member can renew by protocol, the types of lab testing and specified time intervals per medication class, and the visit frequency for clinical monitoring.

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Instead of having the physician as the first to respond to all incoming messages, empower other care team members to manage the inbox. For example, medical assistants or nurses can help by processing prescription renewal requests by protocol or answering some patient questions such as “What was the date of my last tetanus shot?”

Create a systematic approach for inbox coverage when a physician is on vacation or has an absence for an illness or other personal reason. For example, physicians can cross-cover for one another, or doctors and non-physician providers can form a practice team or an on-call nurse for the department can handle the inbox for any physician out of the office.

The AMA STEPS Forward EHR inbox-reduction resource contains more details and concrete examples for each of these nine topics. Also, the “EHR Inbox Reduction Checklist (PDF) is designed to help guide users through the process to eliminate unnecessary burdens and improve workflows. Both of these resources are part of a larger list of practical tools offered to help physicians and health systems get started on several of the new or adapted processes outlined in the “Taming the EHR Playbook.”