After his practice transitioned to an electronic health record (EHR), Green Bay, Wisconsin, family physician James Jerzak, MD, found his day bogged down by sorting through emails that weren’t critical to helping him treat patients on his schedule.

Similar to other physicians’ EHR experiences, Dr. Jerzak found his in-basket clogged with daily progress notes on patients in the hospital, notes on immunizations, pre-visit lab results for upcoming appointments, refill requests and similar matters. When he was done seeing patients for the day, he would spend an hour or more at his desk sorting through emails.

But a team effort by physicians, nurses and medical assistants to tame the office in-baskets has resulted in Dr. Jerzak’s now finding that he is rarely stuck with in-basket work at the end of the day. The practice moved to team-based care and as part of that transition, and medical assistants and nurses help sort and answer emails that once overflowed Dr. Jerzak’s in-basket. Still, the emails are accessible if he needs to see them.

“It is definitely worth the effort,” said Dr. Jerzak, physician lead, team-based care at Bellin Health Ashwaubenon and co-author of the AMA STEPS Forward™ module, “EHR In-Basket Restructuring for Improved Efficiency.”

“We’ve taken a team approach to the in-basket and we make it part of our day,” he said. “Once you get used to the system, you don’t get behind.”

At Bellin, Dr. Jerzak and other team members looked at all the in-basket subfolders and categorized the types of messages they received: symptom-based calls; requests for refills, appointments, medical records, orders or results; and questions about immunizations, medication or a recent office visit. They then sat down together and asked if what was going into each email basket was useful or redundant.

The team determined which person would be most appropriate to handle each type of message or in-basket item. As they answered these questions, at least one person representing each specific role was at the table to help determine that the message was being appropriately routed. With the help of their information technology department, the practice filtered out information that the recipient was not directly responsible for managing.

As part of the practice’s team-based approach to care and in-basket items, here are some of the steps taken by Bellin’s leaders.

Designed team pools. This is one specific location in the EHR that receives all in-basket items for each individual physician or clinician. The  medical assistants and  licensed practical nurses  assigned to that provider are permanently attached to that pool, eliminating the need for them to check into the numerous folders. This eliminates confusion and streamlines management of these items.

Created a protocol. Typically, the medical assistant (MA) or licensed practice nurse (LPN) for a physician’s team logs into the team pool in-basket and manages only that in-basket. In bigger clinics, each team is part of a larger team called a pod so that if a specific team within the pod is out of the office, the other MAs and LPNs in that pod can check the in-basket for the absent team.

Implemented a work flow. All messages go into the team pool in-basket, with exception of triage basket, which allows the work of RNs and  MAs or LPNs to be separated. Instead of having a triage nurse for each provider, the triage in-basket includes messages from all providers in the larger “triage team” or pod.

Changed the status quo. Previously, RNs working triage received all symptom-based calls, handled the majority of results and were the default contact for almost any issue that arose in the office. But Bellin leaders realized it was more efficient to have MAs and LPNs handle some of the messages, especially ones related to a recent office visit. Co-location of teams, where all team members work together in a shared space, plays a key tole in improving in-basket management efficiency. Oral communication, rather that electronic messaging, makes handing of test results, triage questions and other in-basket items much more efficient.

Developed standard messaging templates for receptionists to create a more efficient process that ensures messages get to the right in-basket in a format that is task-oriented, consistent and easily understood by teams.

The STEPS Forward module has more on the changes Bellin made. It also details six steps for physicians to create an optimal, orderly in-basket. The module teaches physicians how to keep unnecessary message from being routed to their in-basket in the first place, guides them through establishing a centralized team in-basket and suggests ways to empower team members to contribute in a meaningful way to in-basket management.

Several modules have been developed from the generous grant funding of the federal Transforming Clinical Practices Initiative (TCPI), an effort designed to help clinicians achieve large-scale health transformation through TCPI’s Practice Transformation Networks. The AMA, in collaboration with TCPI, is providing technical assistance and peer-level support by way of STEPS Forward resources to enrolled practices. The AMA is also engaging the national physician community in health care transformation through network projects, change packages, success stories and training modules.

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