Curbside Consult with Dr. Jayne 5/5/25

An article that was published in the Journal of the American Medical Informatics Association this week addresses the realities of primary care staff members trying to manage the ever-growing volumes of EHR inbox messages. The research was done using qualitative methodology, including focus groups and observations at four academic primary care clinics. The output of those sessions was analyzed and coded into different themes. The study was small, with three nurses and nine medical assistants included. The authors highlighted key themes in the abstract: “Staff described inbox work as fragmented, feeling like an assembly line, requiring frequent communication with other team members to clarify and manage tasks, and requiring navigation of expectations that varied between patients, clinicians, and clinics.”

As someone who has spent a great deal of her career working on process improvement projects, I can feel in my core how the staff must have been trying to articulate a day in the practice. I’ve been around since the pre-EHR world and would note that some of these feelings are not unique to managing an EHR inbox. When we managed paper-based phone messages, we had a lot of these same issues, with the additional problems of having delays in messaging due to having to pull the chart from the file room, or even profound delays when the chart couldn’t be found because it was in a pile on the physician’s desk, their floor, or possibly even in their car or at their home. Working messages in the EHR is certainly faster, which makes one think of the old adage about how technology just makes a bad process go faster.

Seeing these results makes me wonder how much process improvement work the organization did alongside the EHR implementation. Did they spend resources to look at unnecessary process variation and make an effort to try to streamline workflows? If they did, what was the plan for sustaining those changes over time and not allowing the processes to drift back to individual ones?

In a group practice environment, it can be challenging to meet everyone’s needs when each clinician or care team is doing their own thing, and this study seems to illustrate that. The authors noted that there were some protocols available to those working the inboxes, so it sounds like there was at least some work in that regard. They also noted, though, that staff had to address messages that contained information that conflicted with the medical record, which required additional work. We had those issues in the paper world as well, especially when patients called about lab or imaging results that had been done elsewhere and we might not have had a copy at the ready.

In the background section of the article, the authors note that primary care physicians often spend an hour or more managing the inbox for every eight hours of patient care delivered. They also comment that primary care clinicians tend to receive more messages than other specialties and as a result have a higher time burden for inbox management. Not surprisingly, they’re often among the most burned out clinicians. As a result, many organizations are delegating some of this work to support staff, with this concept being studied less than physician work in the inbox, hence the need for this type of research.

The work was done at UW Health, which is affiliated with the University of Wisconsin-Madison, and looked at two general internal medicine clinics and two family medicine clinics. The article notes that they focused on adult primary care practices because those clinicians “receive more inbox messages than pediatricians or physicians in other specialties,” which caught my attention. I think we sometimes think that parents make a lot of calls to their pediatricians’ offices, but I suppose that’s more of a perception and not a reality.

The authors used EHR metadata to identify sites where support staff users were helping manage the inboxes based on functions such as pending medication orders during refill requests for controlled substances. This measure was selected because managing those refills is complex, but uses protocols so that staff can review the chart and pend orders for clinician review. They identified sites with high and low levels of this workflow in order to diversify the sample.

Due to the small number of clinics participating, the number of respondents was low, with some sites having only one medical assistant and one nurse participate, and other sites having three medical assistants but no nurses participate. The most common workflow was where messages sent to clinicians would go to the staff pool rather than directly to the clinician. Members of the pool would then either manage the message or forward it on to a clinician based on protocols.

Some of the fragmentation themes weren’t unique to an EHR workflow, such as being interrupted to bring patients back to exam rooms while also trying to manage messages or having to float to another clinic to cover a staff shortage. Another in that category was the fact that different physicians had expectations that the protocol shouldn’t be followed for their patients, which is not an EHR issue but an operational and clinical quality one. Others were unique to EHR work and particularly pool work,  such as refill requests, coming in through multiple pathways (phone, pharmacy interface, patient portal) leading to three different staff members unknowingly working on the same task.

One of the themes in particular caught my attention, that of limited control, with a staff member commenting, “They made these teams without… asking about how we felt about it.” One of the key tenets of any change management project is to identify stakeholders and understand where they’re coming from. If you don’t do this, it’s nearly impossible to define the “what’s in it for me” needed to support a change management campaign.

There’s a chance that this was done early in the process change, but the people who made the decisions are no longer with the practice. Based on some of the projects I’ve recently seen, there’s also a chance that supervisors made the decisions without discussing with frontline staff. Although that kind of effort can make a project go faster, it’s rarely the right answer for long-term success or happiness of the end users.

The authors note “several fruitful directions for future research,” but I’m more interested to learn what the organization is doing with the information that was uncovered through this study. Have they expanded efforts to collect data from a broader segment of the staff, or looked at experiences in more clinics? Have they compared the protocols from site to site to identify areas of unwarranted variability? Is anyone addressing physicians who are telling staff not to follow an agreed-upon protocol? The devil is in the details for all of those elements when trying to move forward with positive change. If you’ve got the scoop, I’d love to hear from you and of course can keep any comments anonymous.

What do you think is the most successful intervention to reduce inbox burdens for support staff members? Leave a comment or email me.

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