For most family physicians, monitoring email has become as routine as monitoring patients' blood pressure. Every day, FPs must not only navigate their way through a maze of email, but also respond to individual text messages, online prescription refill requests and other electronic communications. Keeping on top of these tasks is critical.
To address this need, physicians and practices have devised various strategies for electronic inbox management. A qualitative study(jamanetwork.com) published online Dec. 27 in JAMA Network Open outlines some of those approaches.
Study Design and Methods
The study group consisted of 24 primary care physicians from eight medical centers within The Permanente Medical Group in northern California. Nine participants were department chiefs; the remaining 15 were frontline PCPs. Two-thirds of the physicians practiced family medicine.
The participants used a comprehensive EHR and an electronic inbox that received messages from patients through a secure portal, as well as messages from other physicians and clinical staff members; pharmacy, laboratory and radiology personnel; and workers in other departments. Messages were accessible on computers or mobile devices, and physicians were expected to reply to all patient messages within two business days.
- Family physicians routinely face challenges staying on top of email communications with patients and managing their electronic inbox.
- A new study reveals the experiences of FPs and other primary care physicians in managing electronic messaging.
- The study also provides a number of individual- and group-level strategies for inbox management.
All PCPs participated in brief interviews with a member of the research team. The team used two interview guides: one for chiefs that focused on group-level strategies for managing electronic messages and another for frontline PCPs that focused on individual experiences and strategies.
After the physicians explained their general approaches to electronic message management, the interviewers asked about more specific topics such as managing patient expectations related to electronic communications, stressors, and opinions on the most effective strategies for managing electronic inboxes.
Several common themes emerged from the participant interviews.
Effects of inbox management on patient care. PCPs noted that adding inbox management to other activities in their clinical workdays caused a marked change in the culture of medical practice, with one physician commenting that "desktop medicine [is] like having a second set of patients."
Participants also had mixed perceptions regarding the increased ease of patient access created by the secure messaging portal. Although a few physicians thought the portal was beneficial and allowed them to develop new skills, others expressed concern that it raised some patients' expectations that they would receive email replies within one or two hours, not days.
Stressors. Every participant reported that electronic messaging led to increased work outside normal work hours. Many PCPs described managing their inboxes after their children went to sleep or while getting them ready for school.
The prospect of responding to unlimited messages was another concern for many PCPs. "No matter what you're doing, you know it's growing," commented one chief who empathized with her group's PCPs. "Growing and growing, constant -- it's 24 hours and it never shuts off."
To reduce the volume of messages received, some PCPs reduced their work schedules by 20% or 30%. This did not necessarily translate to more free time, however, because most participants reported managing their inboxes on their days off.
Individual-level strategies for inbox management. Frontline physicians used a variety of techniques to manage their inboxes. Some PCPs used a "one touch" system, ensuring that they resolved issues after opening an email just once; some made it a point to clear their inbox completely once per day; some reviewed emails between patient visits or while working on other tasks; and some deliberately regulated the pace at which they replied to patients to slow down communication cycles and avoid creating unrealistic expectations.
Group-level strategies. Department chiefs reported creating a number of approaches to effectively manage their groups' inboxes and messages, such as
- setting aside time each workday for inbox management and panel management activities;
- developing and implementing coverage systems to review the inboxes of physicians who were sick, on vacation, had scheduled time off or had some other type of unplanned leave;
- designating a physician as the department's technology lead and having that physician train or meet other physicians individually to discuss inbox management practices;
- providing message management training to medical assistants, which allowed them to co-manage electronic messages with their PCPs; and
- developing templates with "smart phrases" in both English and Spanish that contained standardized replies to common administrative questions.
Noting that no single strategy emerged as the preferred method of inbox management, the research team highlighted the wide range of strategies they observed and suggested that many of them could be tailored to meet the specific needs of individual physicians or practice groups.
The research team also remarked on the fact that the PCPs interviewed were continually investing time and energy into learning how to effectively use and manage electronic messaging. This finding suggested that having structured programs in place could greatly benefit medical students, residents and clinicians in transferring knowledge and learning the skills necessary to become proficient in this aspect of patient care and communication.
AAFP Expert Comments
Steven Waldren, M.D., M.S., an AAFP vice president and the Academy's chief medical informatics officer, has spent much of his career looking for ways FPs can leverage available technologies, including email and messaging tools, to free up more time for patient care.
To Waldren, the study's findings delivered a clear message. "Email management should be part of an intentional strategy that is communicated to staff and patients," he told AAFP News.
Although the FPs in the study all worked for a large medical group, Waldren found some value for solo physicians and smaller practices in the different methods used.
"These are still useful strategies," he said, "but there may be fewer staff to assist with message triage and ongoing maintenance."
Waldren also explained that the Academy is developing a number of educational programs to help FPs better manage their inboxes and electronic messaging. Sessions on this topic will be offered at events such as the AAFP's Physician Well-Being Conference and as part of the Office of the Future exhibit at the Family Medicine Experience, and may potentially be offered at state chapter meetings.
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