Overflowing inboxes were a problem before the pandemic, but physicians and other healthcare workers recently have observed a pronounced increase in screen time — and it’s taking a toll.
Even Bob Wachter, MD, the chair of University of California San Francisco’s department of medicine, tweeted about it last week, calling it the “biggest driver of MD burnout.”
“The messaging has to be recognized,” said Natalie Azar, MD, a rheumatologist and clinical associate professor at the NYU Grossman School of Medicine, who’s been practicing for 20 years. “It’s like quicksand, as soon as you start answering more questions, you’re never caught up.”
Healthcare workers acknowledge that electronic communication has its advantages, but the alerts, notifications, requests, lab results, and direct messages from patients — all contained within their electronic health records (EHR) inbox, often the “In Basket” on EPIC — are contributing to burnout.
It’s especially tough, they say, in the midst of a public health crisis that has leaned increasingly on telehealth and has seen patient health concerns skyrocket.
“The messaging problem, the burden on clinicians, the burnout is not new. This was going on before the pandemic, it’s simply just worse now,” said Harry Saag, MD, also at NYU Grossman School of Medicine, and formerly the medical director for network integration and ambulatory quality there. “I’m not sure how much folks appreciate how much of a problem In Basket is for ambulatory doctors out there. It’s a huge problem.”
Medical informatics experts have offered up strategies for managing the daily deluge, but many workers say it’s still not enough. Most agree on what needs to change: better compensation for time spent messaging, and more broadly, a shift in billing for healthcare services altogether.
The State of the Inbox
With the adoption of online health records and patient portals, online messaging has increased steadily since the early 2000s. In 2003, for example, a study using Health Information National Trends Survey (HINTS) data found that 7% of internet users had communicated directly online with a healthcare provider over the last year. By 2018, another study that used updated HINTS data found the rate rose to 36%.
Others have looked into time spent on inbox messaging. One study that tracked the inbox use of 1,275 primary care physicians found that, on average, they were spending almost an hour in their inbox messages — but that didn’t include time spent pulling up patient records, or other windows they looked at to prepare to answer a message.
“It’s an underestimate for how much time they actually spend on inbox-related work,” said Fatema Akbar, of the University of California Irvine, who led the study.
Another study used EHR data from 573 ambulatory doctors at NYU Langone Health to assess time spent on “work after work,” (but not inbox messaging specifically). All of them spent time on the EHR outside of work, but those with the most scheduled appointments per week actually took on more work than their peers on days without appointments: 2.7 hours a day for those with the fullest weeks (four or more days of scheduled appointments) compared with 15.9 minutes for doctors who worked one day or less with patients.
“We only have so much bandwidth. And that’s why everyone’s working on their weekends, trying to keep up with their notes, their billing and compliance things, their online training,” said Fred Pelzman, MD, a primary care physician and associate medical director at the Weill Cornell Internal Medicine Associates practice (who also contributes to MedPage Today). “I worry that so many people today are putting aside their own wellness at the expense of it.”
Pelzman said he had 17 “baskets” or sub-folders within his EPIC In Basket and if he had to guess, deals each day with 10 to 20 requests for medical advice, 10 to 20 requests for refills, and 10 to 50 copy charts of his patients who had, for example, been seen by other providers who routed their opinions back to him.
That’s on top of what Pelzman said could be 20 to 100 phone messages and another regular email inbox to sort through.
Azar said that if she didn’t periodically check her EHR inbox, she’d accumulate around 30 to 40 messages a day.
Message Type Matters
Notably, a large portion of the EHR inbox burden is automated messages and those that aren’t direct inquiries from patients. These include things like refill requests or notifications that a patient has visited another provider in the health system. “There are hundreds of different types of messages,” said Pelzman.
In fact, one study of the Palo Alto Medical Foundation that included 932 physicians found that messages generated by EPIC far outnumbered those from their patients or coworkers. Of an average of 243 weekly In Basket messages, 114 were automated, 53 were from colleagues, and only 30 were from patients.
The study also drew the direct connection: getting more than the average number of inbox messages was associated with a higher probability of burnout and intention to reduce clinical work time.
Then there are patients who use messaging so frequently it becomes a substitute for in-person care.
“There’s no magic number on the number of questions that you can ask your doctor in the message, but I have had patients send me five or six questions,” said Azar. “If I spent what most of us who are conscientious practitioners and want to be thoughtful about our answers [would], that easily equals a visit.”
She’s had to clarify with patients what an appropriate use of messaging is. But the truth is, there are no agreed-upon standards — especially in the pandemic era when patients are increasingly turning to online communication.
“More and more people are just sicker in general and need more access,” said Adam Szerencsy, DO, medical director of ambulatory clinical informatics at NYU Langone Health. “But since we’ve scaled up telehealth, more people are using the portal and feel more comfortable using technology, so we’re getting more messages. The healthcare system really needs to respond to all of that additional demand that’s now coming through.”
Not an Easy Fix
There’s just more work now — so why don’t healthcare systems and hospitals hire more staff to triage and screen messages?
For one, it’s expensive. “We have some ability to hire people to respond to those types of messages, but the reality is that it’s a cost to do that,” said Szerencsy, referring to the healthcare system as a whole.
“A business model for either a small private practice or even a large academic medical center or hospital system is going to say, is this worth it?” Pelzman said.
The problem isn’t limited to just physicians. Staff whose job it is to sort messages are also feeling the burn. One Twitter user who identified as a triage nurse wrote that hiring more staff, “is a great idea except that I’m answering or forwarding 60+ msgs per 8 hr shift and still have to answer the nursing line, pend orders, help in-person visits, call results to pts, fill out disability forms, etc.”
Even at NYU Langone, which has a dedicated off-site “patient access center” staffed by nurses to triage messages and calls, figuring out the process has been a challenge. For example, Denise Connolly, MS, RN, assistant director of clinical quality operations at NYU Langone, who runs a team of nursing staff at the patient access center, said they tried to tailor their workflow for routing messages to every location differently.
A doctor in one office might want lab results copied into the body of a message, but “invariably somebody will forget, and they’ll copy and paste for the doctor who doesn’t want it copied and pasted, and then their head will explode.” She said they’re implementing a standardized process for the entire system, but for now, “we kind of can’t win.”
Then there’s the issue of reimbursement. Doctors say they aren’t paid appropriately for the time they spend answering messages.
“We’ve got to stop this, we can’t just keep asking doctors out of the goodness of their heart, play on their emotions and say, ‘Hey, can you take one more for the home team?'” said Saag. “Enough of that. It’s just not good enough. It’s not sustainable.”
The other doctors all said they considered message management unpaid work. One physician said they could bill for services that almost fit the description — online monitoring, for example. But another doctor in Michigan, Karl Nadolsky, DO, an endocrinologist and obesity specialist with Spectrum Health, said he does bill for this kind of work.
His administration notified doctors that three new billing codes from CMS as of 2020 cover “online digital evaluation and management services,” which include generating prescriptions, ordering tests, and communication with the patient online (including email), over the phone, or any other digital method. These codes are separate from telehealth services.
Even here, there are a few catches. Newer codes for online care are typically not reimbursed “like a face-to-face encounter,” said Szerencsy. One estimate by a specialized remote monitoring app is $15 for 5 to 10 minutes and $50 for 20 or more minutes of online work compared with, Nadolsky guessed, “well over $100” for an in-person visit.
These three codes only cover messaging that a patient initiates — a small fraction of the total inbox load. Patient messages are also often sent within 7 days of a visit in which “evaluation and management services” were provided face-to-face, which Szerencsy pointed out can’t be billed for, unless it’s for an entirely new problem.
“The reality is that these billable interactions represent a fraction of all of the clinical work we are doing,” he wrote in an email.
Nadolsky said that he and other colleagues have been pushing for a change like this, however, because it would save time and money for the healthcare system, insurers, and patients (who might have a small co-pay, depending on their insurance).
“There’s definitely ways we need to improve, but at least it’s a step in the right direction,” he said.
Szerencsy said that at NYU, they use a number of strategies to reduce the inbox load before it gets out of hand. Many phone calls and messages are routed through their patient access center. For other messages that make it through to physicians, relevant clinical information for a refill is compiled for the doctor so they can avoid having to pull up years-old medical records or separate lab results. They also have support staff “pend” medication orders and refills for physicians to simply sign.
Some unnecessary notifications are even done away with altogether. For example, Szerencsy said, in a situation where a doctor orders a chest CT scan, then another doctor in the system sees the patient and realizes they don’t need one, a notification would be generated for the first doctor. These kinds of alerts could potentially be phased out, Szerencsy said.
The Bigger Picture
But even these updates can’t change another considerably more universal challenge — that of equitable access to healthcare.
Many patient inbox messages come not from the most vulnerable patients, or those who need the most care, but from the younger, more privileged, and educated.
“So many of my patients don’t use email, much less the patient portal. Meanwhile, patients who are tech savvy (and generally more privileged) use the EHR app,” tweeted David Tian, MD, a primary care physician at Highland Hospital in Oakland, California.
A study using HINTS data suggests he’s right. It found that the largest portion of people communicating with their healthcare provider online were also the most highly educated, had the highest income, and had the best health. Another study on health disparities in online communication showed that from 2011 to 2018, the gap between the most and least educated groups in patient-provider messaging had only increased.
Ultimately, experts said, it’s a problem that’s bigger than just a billing code or paring down automated alerts.
“We collectively have created a system that’s transactional in nature,” said Saag. “What we are seeing or will keep seeing is more folks leaving the workforce, more folks becoming burned out.”
“Doctors, they don’t want to put up with it anymore,” he said.
Szerencsy, too, said more widespread changes would need to come from CMS at a policy level to free up more time.
Pelzman summed up an ideal workplace with fewer clicks and more direct care: “If we had to do real doctoring and nurses got to do real nursing and the rest of the stuff happened in the background, that would be a kinder, gentler world.”