Many professions wrestle with the in-box problem – so many messages, so little time. But to appreciate the special challenges faced by medical caregivers, consider these two numbers: 43 million and 87.
Forty-three million is the number of very old and unnecessary emails and other messages that were cluttering the in-baskets of physicians and nurses at the health care system I lead, Michigan Medicine.
Eighty-seven is the number of fixes we have or plan to implement to address an in-box problem that has become a crisis in health care. Addressing the in-basket crisis is one of healthcare’s most urgent challenges. The rule of thumb these days is that physicians spend about two hours completing administrative tasks for every hour they spend with patients. Multiple surveys have found that the in-box issues are one of the leading causes of burnout among providers due to excessive bureaucratic tasks, after-hours workload, and general inefficiencies.
Eighty-seven may not be 43 million, but it is a pretty big number when we’re talking about ways to improve what ought to be a straightforward form of communication. Can most of us even come up with five, or even ten fixes for our own workplace messaging systems? As such, the number 87 symbolizes how complex medicine has become during the last few decades in large part because of technologies that were supposed to streamline and simplify our workflow. What irony!
The problem began brewing a few decades ago with the adoption of electronic health record systems. EHRs promised to improve health care by collecting all of a patient’s medical history and records in a single database that could be read and updated quickly on a laptop or other device. EHRs also included sophisticated message systems that provided caregivers with instant updates on every aspect of patient care.
Any piece of information was just a click away. This proved to be a blessing and a curse. Even as it helped improve care, that easy access soon turned into a hydra-headed beast as various health care stakeholders – from hospital administrators and support staff to insurance companies and various governments – kept suggesting “easy” additions. To take one example, if you can easily CC every member of a patient’s care team on every message, you will. As a result, physicians and nurses have seen their in-baskets swell with notices that other members of the care teams can handle – including appointment scheduling, routine medication refills.
The pandemic then became the straw that broke this camel’s back. The need to limit in-person visits led to the embrace of telemedicine which shifted many appointments to cyber-space. The patient portal increasingly became a prime channel of communication. One COVID-related study found that patient requests for medical advice increased by “157% compared to the of the prepandemic average.” (At Michigan Medicine we saw even more dramatic increases, ranging from two-to-fourfold.) The study’s lead author, A. Jay Holmgren of the University of California-San Francisco, observed last November that such requests may have permanently changed the landscape of medicine. “It looks like this is also part of our new normal, where we have an extremely elevated level of patient demand for this type of asynchronous messaging care.”
Some research estimates that patient requests for medical advice now account for 10 to 30 percent of physician in-basket messages. These requests are important to care, but they also represent yet another new demand on caregiver time, as they often involve questions that used to be addressed all at once during office visits.
Like most every other health care provider across the country – and probably around the world – Michigan Medicine is wrestling with this problem. We have created an “In-Basket 360 Team” to find ways to reduce the amount of excessive bureaucratic tasks, after-hour workload and overall inefficiencies that the in-basket causes care team members and patients. Its team members are the ones who came up with the list of 87 ways we can streamline our system, including the removal of those 43 million outdated messages. Based on their recommendations we are pursuing a policy of addition by subtraction, working to streamline the number of messages caregivers received, so they can focus on those that have the most impact on patient care.
But just as medicine has yet to formulate a magic elixir, there is no panacea for our in-basket challenges. Effective patient care hinges on open lines of communication and real-time information. But too much of even a good thing can become a burden.
There is hope that new technologies may help us limit the problems unleashed by existing ones. That is a tall order, and we must be certain, this time, that the newest gadgets (physical or software-related) do not leave a different kind of “virtual paperwork” and “time-overhead” in their wake.
I personally believe (maybe I should say “hope”) that artificial intelligence systems can help reduce the paperwork that is a key contributor to burnout. Promising new approaches are already being developed to help sort and organize and respond to messages, streamline, improve billing questions, even record, and transcribe patient visits directly into the EHR.
No doubt, these advances will raise their own sets of problems. But two steps forward are worth the price if it only involves one step back.
Marschall S. Runge, MD, PhD, is Executive Vice President for Medical Affairs and Dean of the Medical School for the University of Michigan. He serves on the Board of Directors for Eli Lilly and Company.
