By default, most forms of communication in an outpatient clinic setting are sent straight to the physician’s EHR inbox. And as the physician’s workload grows, so does the volume of the EHR inbox. This creates a significant burden that is impossible to manage alone, causing physicians to spend extra time before or after clinic to complete “between visit” work responding to patient queries and managing clinical information in their inbox.
The extra time spent in the EHR inbox can add as much as two hours to the physician workday, which plays a key role in doctors’ burnout. To solve this burden, health systems must find ways to tame the EHR inbox.
Between 2021 and 2022, the average physician workweek was 56.7 hours—a two-hour increase from previous years, according to an exclusive survey from the AMA. The total number of physician hours spent per week on work-related activities was highest among hospitalists at 64 hours per week, as well as among respondents who were one to five years post training—58 hours a week.
These extra hours of work can cut into a physician’s time at home, increasing the risk of burnout. They have also raised many questions related to burnout, feeling overwhelmed and setting boundaries, including: How can physicians find the right balance between completing in-basket time with seeing patients and taking necessary breaks?
While this question goes beyond what was covered in a recent AMA STEPS Forward® webinar (registration required) that focused on a system-level approach to EHR inbox reduction, two physicians took time to provide some solutions for physicians and health systems to keep in mind.
- Jane Fogg, MD, MPH, a senior physician adviser to the AMA on professional satisfaction and practice sustainability.
- Christine Sinsky, MD, vice president of professional satisfaction for the AMA.
“To reduce the burden of the inbox, we need to go upstream and reduce the number of messages coming into the inbox in the first place,” Dr. Sinsky said. “And then to delegate much of the inbox work to upskill team members who can manage the majority of the inbox messages.
“That way, the physician can spend most of their time on the work for which they’re uniquely qualified,” she added. “So, to reduce the amount of messaging that comes into the inbox in the first place, we recommend ‘DC the CC’—discontinue the CC’ing of charts, the CC’ing of visit notes from one doctor to another unless there’s something very specific the originating physician wants to convey to the receiving physician.”
Another way to tame the EHR “is to do ‘90 x 4,’ which means 90 days plus four refills for all chronic stable medications and to renew them all simultaneously at the time of an annual appointment for each patient,” Dr. Sinsky said. “That eliminates multiple contacts from each patient throughout the year.”
Additionally, “doing laboratory tests prior to the visit reduces the number of inbox messages that the physician reviews and responds to, as the test results can be reviewed and discussed face-to-face with the patient at the time of the visit,” she said.
“We have to give the doctors and their teams the support to do it. We have to put our feet down,” Dr. Fogg added. “This is a problem we can’t ignore, especially for primary care as our delivery systems depend on primary care physicians for access, growth and great outcomes.”
“If you’re an organization of 100 physicians with average rates of burnout and a very conservative estimate of the cost to replace that physician of $500,000, that organization is already spending almost $1.5 million a year replacing physicians who leave solely because of burnout. And that’s really expensive,” Dr. Sinsky said. “You can reduce that turnover related to burnout and you can increase your productivity by having more staff to help with activities such as the inbox.
“If you have one extra staff person—medical assistant or nurse—helping with patient care activities, including the inbox, for two different physicians, that allows each of those physicians to both see one more patient a day and go home one to two hours earlier or not be doing several hours of work at night,” she added. “That’s a slam dunk for the organization.”
Additionally, “it’s important for physicians to recognize that if you invest an hour today in training your staff on how to handle most of the inbox messages on their own and for those messages that require physician input you can talk about them face to face, you will save 30 minutes every day going forward,” Dr. Sinsky said. “Investing a little time upfront to develop the processes where your staff can manage the majority of the inbox messages will save you time in the long run.”
“At the individual physician level, it’s important to recognize that the inbox is not the place for patients to access care for urgent needs,” Dr. Sinsky said. “Physicians should communicate that through standard information given to patients about the portal when they sign into it.”
Additionally, patients should be informed “that the team will answer their questions during normal business hours,” she said. “And then physicians can reinforce that by responding only during business hours.”
“That reinforces to patients that it is not a 24/7 means of communication and sets appropriate expectations so that they don’t go to the portal anticipating 24/7 access to their physician,” Dr. Sinsky said. Similarly, when physicians are on vacation, they should not be required to cover the in-basket, Dr. Sinsky said.
“It is not a good business model to have the highest-trained individual spending much of her time doing work that a person with lower training and lower costs could be doing,” she added. “If physicians aren’t able to set boundaries on their time, it’s a high-risk factor for them leaving that organization to practice elsewhere or leaving medicine altogether.
Additionally, “it is important to structure the care environment to maximize physicians’ ability to provide undivided attention to our patients—whether it’s the patients we’re seeing in person or the patients we’re caring for via the portal,” Dr. Sinsky said. “Sharing elements of care, such as inbox management, with an upskilled team member allows the physician to provide more undivided attention to patients.”
“And that is a tragedy when that happens because we are already short of physicians, particularly physicians in the primary care specialties,” she said. “That’s one of the reasons the AMA is investing in and developing resources to establish best practices.”
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.
When it comes to balancing in-basket time, direct patient care, breaks in the day, “there’s no one solution for every physician,” Dr. Fogg said, noting “some people work in certain patterns that work for them.”
For example, some physicians will dedicate 20 minutes to in-basket work every two hours, followed by a “20-minute break after,” Dr. Fogg said. “And then, of course, you have to adjust lunch timing, but it helps some people.”
It’s about breaking up the day in a way that works for each physician, Dr. Fogg explained. Before EHRs, some physicians might have taken an hour in the afternoon to return phone calls, “which meant they weren’t seeing patients. It also meant that patient calls were managed during the workday when other team members can assist, such as scheduling the patient to come in or calling in a prescription.
“So, there is precedent that you could develop some time that works best, but there isn’t any magic to it other than figuring out how to time it for your needs,” she added.