Busy primary care physicians receive more than 100 EHR inbox messages per business day. Most health systems are looking for ways to relieve this burden. During a recent webinar hosted by the American Medical Association, Jane Fogg, M.D., M.P.H., executive chair of internal medicine at Boston-based Atrius Health, described the systematic approach her organization is taking, which includes a strategy of combining elements of “elimination, automation, delegation and collaboration.”
Since 2016, Atrius, which has 30 locations in eastern Massachusetts, has been able to reduce its primary care providers’ total message volume by about 25 percent. “We're not done yet,” Fogg said, “but this shows we've actually made some real progress.”
Fogg said Atrius realized that achieving these results would require several approaches. “We 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,” she said.
She said the place to start is to get an understanding of your current state. “You really want to explore quantitatively and qualitatively what's happening in your in-basket at your institution. Certainly, we start with the volume of messages and how we measure that,” Fogg said. She added that it was important to assess the intent of the messages. Did the physician need to see it or did somebody else need to see it? “Because that leads us into who is really the ideal team member to address that particular message type. Typically, today, most organizations route things to a physician and expect that they will then send it on to other folks on their team to take next steps. I don't think that's a durable solution. There's simply too much volume coming at us. We need to get it to the team first, and they need to delegate up to the physician.”
How you start on a project like this is just as important as who you involve. “One might assume that we should just involve clinicians and get together design what they think would be best and ask someone to build it for them. I would actually argue that if you combine your clinical, your technical and your operational experts at the very beginning of your work, you're going to find solutions you didn't know where possible,” Fogg said. “The co-development of solutions between the technical experts and the clinical experts led us to find new ideas. As an example, we didn't know we could eliminate certain routing pathways. We didn't know why some things were getting routed into our in-baskets. When we sat down together to examine what we wanted to do, we learned from our technical experts, and they learned what was important to us, both the clinical leaders and the operational leaders. We really blended new perspectives on what inbox design could be by sitting at the table from the beginning.”
In order to have success with delegation, it's important that you have a strong team structure, Fogg said. “You can't start delegating in the inbasket if your clinical practice doesn't have a good team structure to build off of. Collaboration, I think, is such a key point. Most inbaskets were designed as if there's so a singular user and that's all that's needed. The reality is that the inbasket is clinical information, its clinical care, and it belongs to the team. We need to figure out how we can have multiple people participate.”
She gave a few examples of places Atrius started. One was with CC Chart, which is a “carbon copy” note that is sent to primary care by a specialist or urgent care colleague. “When we looked at this back in 2017, it was 16 percent of our total message volume.
The volume was too big, but then we actually started looking at the messages themselves,” Fogg explained. Many of them held low clinical value, such as “It was a normal dermatology check. We'll see them next year.” Or “Saw them for sore throat; did a strep test; gave me antibiotics” — things that the practice doesn’t actually need to take an action on.
When there was something valuable, such as a specialist making a new diagnosis of significance to your patient, the CC Chart was sent and you had to read the whole thing to find that, she said. “We looked at that and we saw this high variation in clinical value,” Fogg said. The first thing they did was get rid of automatic routing of these messages. They set up practice agreements with colleagues on what to send Atrius. They then purged any CC Chart out of an inbasket that was over 60 days old. “We quickly achieved about a 40 percent reduction, which persisted,” she said. “We found that people were saying now when I see a CC Chart, I know it's more likely to have something valuable for me.”
An example involving automation took on prescription renewal requests. They were seeing 16 per day per full-time PCP in 2017. “We wanted to find a solution to automate this and we wanted to move quickly, so we decided to work with an outside vendor that had a mature product that was essentially an automation platform that we could put right into our electronic health record,” Fogg said. After pilots at two sites, they spread it to 21 clinics. “In the adult primary care space, we reduced the prescription renewals that go to the PCP inbasket by 50 percent. They do not require a physician to sign off on them. They are automated under the physician’s name. It continues to work well.”
Fogg stressed the importance of engaging your chief medical information officer and EHR leaders. “They need to be at the table with you because much of this is technical and you need to be together to make those decisions and find your opportunities,” she said. “A second important piece is about decision making. I find that a lot of us don't know who made the decision that somebody's sending me this document. Do I need to see it? Who decided that it was sent to me? I hear that from PCPs every day: Why am I getting this? You can make decisions about what you and your team should see. And if you employ clinical governance and you think about the clinical value, about safety, about all those parameters, I think you will find there are a lot of decisions you can make, but that you actually don't need to see or could be seen by somebody else.”
Sometimes you need to standardize a certain workflow to achieve something such as automation, Fogg added. “We had to have certain standards in our refill management in order to automate refills for 350 providers. We couldn't customize it to each individual provider. It is important to think about standardization in the right spots where it allows you to drive forward something that supports everybody.
Remember, she said, that a good inbasket is only as good as your team. “Think about your team roles and how your M.A.’s, nurses, and everybody else on your team works today.”