In addition to clinic visits, physicians must also keep up with important patient information in their electronic health record (EHR) and its "inbox" messaging system, where they receive notifications similar to an email inbox. While this is a convenient way to communicate important patient information related to test results, medication refills and events such as hospital discharges, overload from the EHR's inbox can lead to physician burnout, job dissatisfaction and patient safety risks. In a study just published in the Journal of General Internal Medicine, researchers at Baylor College of Medicine recommend strategies for managing EHR inbox notifications.
Researchers used two sources of data, evaluation of findings from a Department of Veterans Affairs survey of primary care practitioners about recommendations to improve EHR inboxes, and interviews with physicians from five different health systems including Baylor and its affiliate, Michael E. DeBakey VA Medical Center.
"We asked what strategies they used in order to best manage this influx of information, including use of specific EHR features, workflow features, organizational support, or even delegating some of the responsibility of managing this to their staff," said Dr. Daniel Murphy, assistant professor at Baylor and the Houston VA Center for Innovations in Quality, Effectiveness and Safety (IQuESt) and the lead author of the study. "We looked at what types of things they were doing to keep up with EHR, which allowed us to identify strategies that we can disseminate to others who are having similar problems."
"This work is important and timely because physicians feel quite overwhelmed with EHRs," said co-author Dr. Hardeep Singh, chief of the Health Policy, Quality and Informatics Program at the Houston VA's IQuESt and professor of medicine at Baylor. "Some of the increasing burnout in health care could be attributed to these electronic health record inboxes."
Singh said his team's previous study on EHR inbox workload found that physicians receive an average of 70 to 75 new inbox notifications per day. He explains this not only leads to what is now known as "pajama time," or extra hours spent with the EHR at home, but also may cause them to miss important information related to their patients.
"In previous work we found that about a third of clinicians said that they missed abnormal test results because they were overloaded with too many inbox messages," Singh said. "The more information that keeps getting pushed to frontline clinicians through the EHR, the higher the risk they may miss something."
On analysis of interviews and survey responses, the researchers outlined five main areas for changes that could improve inbox management:
Inbox messages should be relevant to patient care and the clinician: While most EHR messages are essential, many are unrelated to patient health and the physician. The findings show that physicians want fewer "for-your-information" messages and ones that contain duplicate information, which would lead to less overall messages.
Inboxes should reduce risk of losing messages: In some EHR inboxes, messages can inadvertently disappear on their own and without a way to easily retrieve them. This can cause risks of losing important information.
Inboxes should have an easier way to process messages: Accessing certain information in the EHR inbox is not always simple. Murphy explains that physicians have to go through multiple steps to view information in one message and that it can be difficult to sort, prioritize and take action on them in the inbox. Better inbox design could help.
Providing additional help to check inbox notifications: Murphy explains that not everything that is sent to the inbox needs to go to the physician. Staff could help filter out messages that do not require the expertise of clinicians.
Sufficient time for clinicians to process EHR inbox notifications: There should be sufficient blocks of time during the day that physicians can review their messages without having to check them at home. Murphy said it can take over an hour a day just to manage inbox messages, and few organizations provided this amount of time.
Murphy and Singh state that the next step is a push for policy changes both locally and nationally to ensure that clinicians are supported in this work and care is safe and efficient. The researchers encourage physicians, administrators, health information technology personnel and EHR designers to work together to create a more efficient inbox that minimizes burnout and safety risks.
"We hope that health care organizations will closely examine workloads related to their EHR inbox, implement changes to reduce burden, review teams and workflows that support inbox work, and ensure they have the right staffing models," Murphy said. "At the same time, vendors who develop these EHRs need to understand clinicians' needs and implement recommendations we provide herein."
