Docs Add 1 Hour of Administrative Work for EHR Inbox Management

Primary care physicians (PCPs) spend roughly an hour on EHR inbox management per day, and the majority of this time is spent outside of scheduled work hours, according to a study published in the Journal of the American Medical Informatics Association (JAMIA).

Patient portal messages and results consume the highest proportion of PCP EHR inbox time.

Managing an EHR inbox has become a regular part of clinician workflow, often resulting in clinician burden.

The inbox receives patient portal messages and messages from other clinicians, the pharmacy, laboratory, and other medical departments. Most clinicians should reply to messages within two business days, according to study authors.

While numerous studies show how EHR inbox management correlates to clinician burnout, there is limited research about inbox use patterns. Researchers aimed to analyze the amount of time clinicians spend on inbox management, assess daily use patterns, identify the variation of inbox messages received, and dissect the associated factors of high inbox usage.

Researchers analyzed one month of EHR inbox data for over 1,200 physicians in the Permanente Medical Group, the country's largest medical group.

PCPs spent an average of 52 minutes on inbox management, with 33 minutes during work hours and 19 minutes or 37 percent of total inbox management outside of work hours during the workweek.

On non-workdays, the respondents spent roughly 12 minutes on the inbox, but the total ranged from zero to 93 minutes.

During the workweek, researchers found physicians had about 100 message views per day on average and 53 views outside of work hours. On non-workdays, physicians viewed about 33 messages a day.

“The high number of views may be due to physicians needing to switch screens between the inbox and other parts of the EHR to find information to reply to messages or to take other actions, indicating a high rate of task switching within inbox work itself,” explained the study authors.

“Given the associations between multitasking and stress, physician patterns of multitasking with the electronic inbox warrant further study.”

Researchers found most physicians managed the inbox during lunch hours or before and after work hours when identifying inbox management patterns.

Researchers also compared inbox management to other EHR functionalities, such as order entry, charting, and chart review. Respondents increasingly utilized the other functions more than the inbox throughout work hours but focused more on inbox management during lunch hours.

On non-workdays, both overall EHR and inbox use had flatter patterns than workdays. As can be expected, there is a large variance across individual users in the amount of time spent on the EHR and the inbox per hour.

Twenty-eight percent of messages consisted of patient messages, 29 percent were patient results, 25 percent were patient requests, and 11 percent were administrative messages. On workdays, PCPs mostly utilized desktop or laptop computers to manage the inbox, while on non-workdays, the respondents commonly used a mobile device to access the inbox.

Researchers said the results suggest potential EHR inbox design optimization to reduce time spent in the EHR.

“Given the high number of message views (ie counts of switching to the inbox page), a system design consideration would be to implement an interface that incorporates information that physicians need from sources outside the inbox page (eg patient data) to process an inbox message, thus reducing potential frequent switching between the inbox page and other windows,” wrote the study authors.

Researchers also suggested limiting inbox management to only one or two times a day, also known as batching, rather than checking messages throughout the day.

However, researchers noted batching might only be useful in particular medical settings.

“It is possible that the messages being checked in between patient visits are those that are more clinically urgent, making batching infeasible,” wrote researchers. “Thus, the feasibility and desirability of batching inbox time in medical contexts is yet to be evaluated. Another practical implication for inbox system design is to implement screening and categorization of patient-initiated messages, automatically or by assistants, which can help PCPs prioritize or delegate some messages.”