Electronic Health Record Inbox Management

Most practitioners receive communication and information from patients and other healthcare professionals by way of the electronic health record (EHR) inbox. Messages, test results, consultation requests, referrals, medication refill requests, direct messages from patients via patient portals, and other types of electronic communication are transmitted in this centralized hub.

On average, practitioners spend about 84 minutes per workday managing EHR inbox content. As the use of remote monitoring devices, medical grade sensors, health applications, cloud computing, and data analytics continues to expand, the corresponding influx of inbox messages is likely to add to this administrative burden.

Current inbox-related workloads are unsustainable in the long term and can lead to burnout and lower life satisfaction levels. A recent study found that primary care physicians who receive a higher daily number of electronic messages are more likely to experience burnout symptoms. According to these researchers, every 10 additional messages per day increase physician odds of experiencing burnout by 40%.

Additionally, excessive EHR inbox messages can impact situational awareness, making it difficult for practitioners to focus on relevant messages, understand their meaning, develop reasonable expectations based on message information, and take decisive action. Enhancing the visibility of key clinical information allows practitioners to identify and focus on more urgent messages. Practitioners with sufficient time to thoughtfully consider and comprehend clinical information, project future status, and take appropriate action will achieve better patient outcomes.

Risk Recommendations 

Managing the EHR inbox notification workload can increase practitioner satisfaction and reduce safety risks resulting from information overload. Consider the following when reviewing your organization’s EHR inbox management system: 

• Analyze inbox data. Evaluate your current inbox status to determine the number and type of practitioner inbox messages. This can help identify areas with the most potential for improvement.
• Identify unnecessary communications. Work with an interdisciplinary team to review practitioner inbox notifications that may be unnecessary such as certain automated carbon copy functions, information-only messages or unscreened patient portal messages. Consider whether some of these notifications can be excluded without compromising patient safety. 
• Prioritize messages. Not every message requires urgent or immediate attention. Optimize and enhance EHR features to sort, filter, and flag messages for higher relevance and priority. Establish protocols to handle emergent and urgent messages. Train staff to identify and forward messages that impact patient care and monitor/evaluate for compliance.
• Utilize team support. Work with an interdisciplinary team to develop message management systems that leverage staff member skills, streamline processes, and enhance patient safety. Consider incorporating the following into your inbox management system:
  • Enable message forwarding to team members and include comments for instruction or context in EHR inboxes.
  • Teach staff how to screen messages and manage tasks within their scope of practice. Train staff to gather all necessary information before forwarding messages to practitioners.
  • Synchronize annual prescription renewals to reduce refill calls.
  • Instruct staff to complete demographic information on forms or orders (e.g., preauthorization forms and disability forms) before routing them to practitioners.
  • Develop and implement a consistent process for practitioners to review, sign, and date test results and consultation reports.
• Manage the patient portal. Since 2020, inbox messages from patients via the patient portal have increased 157%. While the portal is a great tool for engaging patients in their own healthcare, overused or inappropriate portal communication can burden the practitioner. Consider the following when evaluating your patient portal policies:
  • Set expectations with patients. To avoid misunderstandings, educate patients in advance about how and when to use the portal to communicate with the healthcare team. Develop a written “Patient Portal User Agreement” that addresses:
    • How and when patients should communicate through the portal and when they should expect a response.
    • How patients should request medication refills and how much notice is required to do so.
    • Acceptable portal use (e.g., requesting an appointment, reviewing previously communicated lab results, tracking immunizations).
    • Unacceptable portal use (e.g., sensitive or time-sensitive reporting, such as abnormal diagnostic results, urgent or emergent matters, and signs or symptoms). Specify the consequences for unacceptable use.
    • Billing policies, if any, arising out of responding to portal communications.
• Optimize portal design. Set specific guidelines for patient portal communication and display them prominently in the portal. Clearly define and display message types that are not appropriate for portal communication, such as those regarding time-sensitive or sensitive matters, urgent/emergency situations, or abnormal results. Define urgent/emergent medical matters and consider including a bold pop-up message instructing users to call 911 for emergencies. Require each user to register with a unique name and password and restrict the message character count. Work with your billing department to explore the possibility of obtaining reimbursement for certain types of messages exchanged via the patient portal. Post your billing policy for responding to patient messages in a prominent place in the portal.
• Establish guidelines for portal message management. Work with an interdisciplinary team to determine which types of inquiries staff can manage within their scope of practice, e.g., medical records requests, billing inquiries, and appointment requests. Train staff to effectively recognize, prioritize, and escalate such messages, and provide written instructions on how to address these inquiries. To ensure consistency and efficiency, develop standardized message templates that staff can use to respond to routine inquiries or frequently asked questions.
• Keep abreast of evolving technology. Some organizations are exploring the use of artificial intelligence (AI) chatbots to handle some patient portal questions. These chatbots utilize conversational AI technology to improve the overall patient experience. In fact, a recent study found that patients preferred responses from chatbots over doctors, rating chatbot communication higher in terms of both quality and empathy. While AI-powered chatbots can be beneficial for addressing administrative or clerical inquiries, they cannot replace human interaction and a healthcare professional’s expertise when addressing clinical information. Monitor this technology as it continues to evolve to determine if it can be utilized to enhance the patient experience and improve efficiency.
• Allow uninterrupted time. Give practitioners enough “protected” private time during their workday to process inbox messages in a distraction-free environment. This allows them to fully understand and respond to messages and make informed decisions without feeling rushed.
• Provide absence coverage. Develop a systematic approach to cover inboxes for absent practitioners. Delegate inbox management to another practitioner. Provide inbox access and instructions on how to handle different types of messages. Consider implementing a "Doc of the Day" rotation to assign a practitioner without patients for that day to cover the needs of a practitioner on vacation or with a day off.

EHR inbox management can have a profound impact on practitioner well-being and patient safety. There are a variety of practical solutions for effectively managing electronic inboxes. It is up to each organization to determine which strategies work best for them. 

Additional Resources

• American Medical Association (AMA). Taming the EHR Playbook: Resources.
• American Medical Association (AMA). 5 ways physicians can find relief from an overloaded EHR inbox