Already a member or subscriber? Sign in now

Advertisement
Previous article
Caring for Family Members of People With Substance Use Disorder: Practical Strategies
Nov / Dec 2024
Next article
How Should We Measure Success (or Failure) in Primary Care?

In-Basket Zero: Five Time-Saving Principles for Physicians

STEPHEN K. STACEY, DO
TEJAL SHELAT, MBBS
KELSEY ROLEFSON, DO
HENRY LOSSEN, MD
PARIVASH BADAR, MBBS, MD

FPM. 2024;31(6):30-34.

Author disclosures: no relevant financial relationships.

Many physicians have resigned themselves to working after hours to keep up with their in-basket, but it doesn't have to be this way.

While patient care should be the primary task of a clinician, studies indicate that for every hour spent on direct patient care, physicians devote nearly two hours to electronic health record (EHR) management and desk work during the clinic day.1 The professional in-basket has become inundated with tasks ranging from prescription refills to test-result notifications to patient messages, all requiring timely responses. When physicians don't have enough time to tackle the in-basket during the workday, it encroaches on their personal time outside of clinic hours, becoming at-home work colloquially referred to as “pajama time.”

Physicians with four to five days of scheduled appointments per week spend an average of 22 minutes on this “work after work” on scheduled days and 2.8 hours on unscheduled days.2 While EHRs were intended to improve physician efficiency, they have instead allowed work to invade home life more than ever, contributing to fatigue and burnout. One study indicated that most physicians experience fatigue within 22 minutes of engaging with the EHR.3 Physicians who spend more time on the EHR after hours and those whose in-baskets exceed 114 messages per day are more likely to experience emotional exhaustion.4,5 Many have resigned themselves to working nights and weekends to keep up with their in-basket, but it doesn't have to be this way.

Physicians can minimize or eliminate pajama time by embracing a concept we call “in-basket zero,” aimed at keeping their in-basket empty or nearly empty at all times. This is similar to “inbox zero,” a rigorous approach to email management developed in 2006 by author Merlin Mann. Inbox zero was based on five tenets:

  1. Some messages are more important than others. They don't all require the same time and attention from you.
  2. Your time is limited, and you must choose how to use it.
  3. Less is more when responding to messages.
  4. Lose the email guilt. It won't help you solve the problem.
  5. Be honest and realistic about your priorities and time expectations.

In this article, we have adapted Mann's five tenets and applied them to the task of managing a clinician's in-basket.

KEY POINTS

  • To reduce or eliminate “work after work,” allocate at least 25% of each patient visit for in-basket management. Agenda setting, team empowerment, and effective communication can help create this capacity.
  • For each in-basket message, promptly take one of the following actions: delegate, defer, or do.
  • Less is more when it comes to charting. Avoid “note bloat” and unnecessary details, and focus on information essential for memory, communication, billing, and medicolegal purposes.

Dr. Stacey is assistant professor of family medicine and director of osteopathic education, La Crosse-Mayo Family Medicine Residency Program, La Crosse, Wisc.

Drs. Shelat, Rolefson, and Lossen are residents at La Crosse-Mayo Family Medicine Residency Program.

Dr. Badar is core faculty, La Crosse-Mayo Family Medicine Residency Program.

Send comments to fpmedit@aafp.org, or add your comments to the article online.

Author disclosures: no relevant financial relationships.

  1. 1.Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in four specialties. Ann Intern Med. 2016;165(11):753-760.
  2. 2.Saag HS, Shah K, Jones SA, Testa PA, Horwitz LI. Pajama time: working after work in the electronic health record. J Gen Intern Med. 2019;34(9):1695-1696.
  3. 3.Khairat S, Coleman C, Ottmar P, et al. Association of electronic health record use with physician fatigue and efficiency. JAMA Netw Open. 2020;3(6):e207385.
  4. 4.Adler-Milstein J, Zhao W, Willard-Grace R, Knox M, Grumbach K. Electronic health records and burnout: time spent on the electronic health record after hours and message volume associated with exhaustion but not with cynicism among primary care clinicians. J Am Med Inform Assoc. 2020;27(4):531-538.
  5. 5.Tai-Seale M, Dillon EC, Yang Y, et al. Physicians' well-being linked to in-basket messages generated by algorithms in electronic health records. Health Aff. 2019;38(7):1073-1078.
  6. 6.Stacey SK, Morcomb EF. Five steps to mastering agenda setting. Fam Pract Manag. 2021;28(2):27-31.
  7. 7.Harper PG, Van Riper K, Ramer T, et al. Team-based care: an expanded medical assistant role — enhanced rooming and visit assistance. J Interprof Care. 2018;37(sup1):S95-S101.
  8. 8.Kortlever JT, Ottenhoff JSE, Vagner GA, Ring D, Reichel LM. Visit duration does not correlate with perceived physician empathy. J Bone Joint Surg Am. 2019;101(4):296-301.
  9. 9.Jalota L, Aryal MR, Mahmood M, Wasser T, Donato A. Interventions to increase physician efficiency and comfort with an electronic health record system. Methods Inf Med. 2015;54(1):103-109.
  10. 10.Apathy NC, Rotenstein L, Bates DW, Holmgren AJ. Documentation dynamics: note composition, burden, and physician efficiency. Health Serv Res. 2023;58(3):674-685.
  11. 11.Rotenstein LS, Apathy N, Holmgren AJ, Bates DW. Physician note composition patterns and time on the EHR across specialty types: a national, cross-sectional study. J Gen Intern Med. 2023;38(5):1119-1126.
  12. 12.Blackley SV, Schubert VD, Goss FR, Al Assad W, Garabedian PM, Zhou L. Physician use of speech recognition versus typing in clinical documentation: a controlled observational study. Int J Med Inform. 2020;141:104178.
  13. 13.Kadish SS, Mayer EL, Jackman DM, et al. Implementation to optimization: a tailored, data-driven approach to improve provider efficiency and confidence in use of the electronic medical record. J Oncol Pract. 2018;14(7):e421-e428.
  14. 14.Akbar F, Mark G, Prausnitz S, et al. Physician stress during electronic health record inbox work: in situ measurement with wearable sensors. JMIR Med Inform. 2021;9(4):e24014.
Previous article
Caring for Family Members of People With Substance Use Disorder: Practical Strategies
Nov / Dec 2024
Next article
How Should We Measure Success (or Failure) in Primary Care?

Latest issue

September / October 2026

September / October 2026

Copyright © 2026 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. See permissions for copyright questions and/or permission requests.