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.

MAKE TIME FOR THE IN-BASKET DURING THE WORKDAY

To achieve in-basket zero, clinicians need to balance the time they spend on in-basket tasks versus patient care during the workday. A typical clinic schedule allocates most of the workday to direct patient care with no built-in time for administrative duties. But if you spend every minute of every encounter face-to-face with patients, then you won't be able to complete in-basket tasks until after clinic hours.

The reality is that physicians need scheduled time for the in-basket, including EHR tasks and messages. One way to accomplish this is to spend slightly less time with patients in order to complete all the non-face-to-face work. By dedicating around 25% of each patient encounter (e.g., five minutes of a 20-minute appointment) to in-basket management, physicians can conceivably attain in-basket zero by the end of the workday and reclaim their personal time.

To effectively shorten patient visits by 25% while preserving quality of care, the remaining 75% of the encounter must be used efficiently. Consider the following strategies:

• Agenda-setting. Agenda-setting allows you to prioritize patient needs within the time constraints of the visit.⁶ It begins with the physician or rooming staff eliciting all patient concerns at the outset of the visit. After the patient's initial response, asking “What else?” or “Any other concerns?” (as opposed to “Any other questions?”) can effectively produce a complete list. Next, quickly estimate the time required for each item on the list and collaborate with the patient to prioritize what you need to address immediately versus what can wait for subsequent visits. Finally, confirm the patient understands and agrees with the shared plan to address their concerns. This process can enhance patient satisfaction and prevent the tendency to try to address too many issues in a single visit.

• Empowering support staff. The patient's first points of contact are scheduling, front-desk, and rooming staff, and those interactions set the tone for the visit. Rooming staff can help compile the list of patient concerns and help set expectations for what can be addressed during the visit. They can employ standardized templates while gathering patient histories to streamline the process, allowing physicians to enter exam rooms better prepared and avoid redundant discussions. Similarly, pre-preparation of supplies for procedures and pending orders for immunizations or routine health maintenance tasks can further expedite clinic workflows. For some clinics, this may involve expanding the role of medical assistants (MAs) or nurses by allowing them to pend orders while rooming, enter orders per protocol, assist with patient education after the visit, and print after-visit summaries. Allowing staff to work at the top of their license improves not only physician efficiency but also patient satisfaction and quality of care.⁷

• Communicating effectively. Effective communication strategies and physician empathy have been shown to increase patient satisfaction regardless of how much time you spend with the patient.⁸ Once you've set the visit agenda with the patient, let them express their experiences fully. Engage in active listening, ask pertinent questions, and demonstrate empathy while guiding the conversation to maintain focus. Leveraging the EHR as an educational tool and sharing your screen when appropriate can also enhance the patient interaction. When discussing the assessment and plan, check for patient comprehension and provide necessary clarification before concluding the visit. These simple steps can reduce patient questions and messages following the visit, ultimately saving you time and creating a more satisfying visit.

CAREFULLY MANAGE YOUR LIMITED TIME

Physician efforts are the rate-limiting step in health care, so your individual work efficiency directly influences how quickly the overall work gets done. It also determines how much time you spend after hours on the in-basket. Documentation tasks, patient messages, test results, and refill requests are time-consuming enough on their own, but they take even longer when we delay decisions and have to re-read messages, sometimes multiple times. The first time you read an in-basket message, take one of the following actions:

• Delegate. Whenever possible, quickly delegate or forward in-basket messages to appropriate staff. Enlist the support of MAs and nursing staff to triage tasks, ensuring that only matters requiring your expertise end up with you. Moreover, when your input is required, staff should gather necessary details beforehand to help you formulate an appropriate response. For example, MAs can complete forms before forwarding them to you. Nurses can pend orders or sign certain orders per protocol. If a patient is late for follow-up and making a request via messaging, staff can work to schedule a visit with that patient.

• Defer. While you should aim to take immediate action on each in-basket message, not all messages can or should be completed immediately. For questions about labs that haven't returned yet, controlled substance refills that should be delayed, or too-frequent patient messages about non-urgent issues, the appropriate action may be to defer the message. Most EHR systems offer a “defer” or “postpone” option. Getting the message out of your in-basket — even temporarily — means you don't have to take time to think about it repeatedly.

• Do. If you know what action you should take to complete an in-basket message, do so immediately whenever possible. When charting patient encounters, remember that opening and entering the patient's chart takes time. Try to limit the number of times you enter the chart for each patient encounter to just three: once before going into the patient room, again inside the patient room, and once more to document the visit. Aim to have your documentation done before going into the next patient encounter.

LESS IS MORE WHEN IT COMES TO CHARTING

Encounter notes can be the most time-consuming part of the in-basket. Notes should be concise and relevant. Focus on documenting details for your own memory, for communication to the medical team, and to fulfill billing and medicolegal requirements. Documentation beyond the minimum required for these purposes is a waste of time. Your notes should anticipate the information needs of other providers while maintaining simplicity and relevance. Keep questions and plans clear and obvious to facilitate efficient communication and decision-making. Avoid unnecessary details, which take time to record and time to read later on.

Many modern documentation practices enable “note bloat,” or the proliferation of extraneous information. For example, dictation is a useful tool, but it presents an opportunity to ramble, resulting in unnecessary text in the chart. Templates and smart phrases (also called macros, dot phrases, or quick phrases) can expedite documentation and maintain relevancy as long as they do not include extraneous information or data that the clinical team can easily obtain from chart review. Excessive use of these tools may actually reduce EHR efficiency.^9,10 For example, one study found that physicians who primarily use transcription and dictation spent less time on note writing (an average of 4.8 minutes per visit) compared with physicians who primarily use smart tools (an average of 7.8 minutes per visit).¹¹ Copying and pasting information easily available elsewhere in the chart also adds time (an average of 13.1 minutes per visit).¹¹ Typing notes may be the slowest form of documentation. Speech recognition has been found to save time, increase efficiency, reduce errors, and enable quicker documentation of more relevant details than typed notes.¹² Alternative approaches such as medical scribes and artificial intelligence tools also present opportunities to streamline workflows.

DON'T FEEL BAD

Physicians often feel bad about the state of their in-basket and their overdue EHR tasks. But they also often feel guilty about setting boundaries and doing what it takes to effectively manage their in-basket. These negative emotions are unhelpful. Below are six things you should not feel bad about:

• Don't feel bad about ending visits “early.” Charting the encounter and responding to test results and other correspondence are part of what goes into each appointment. By spending some time during each encounter on the in-basket, you're using the appointment time for its actual purpose.

• Don't feel bad about waiting to respond to certain messages. You do not have to respond immediately to non-urgent messages. Most EHRs can remind you to address messages later. The advantage of waiting is that you can often avoid prolonged conversations with rapid back-and-forth communication. This is especially true for patients who message frequently.

• Don't feel bad about asking patients to come into the clinic. You do not have to address all patient complaints via the in-basket. Some, such as new complaints that have not had a prior workup, should prompt an in-person visit.

• Don't feel bad about using the EHR and charting in front of the patient. People understand that you have to look up and document their information. For new patients, explain at the beginning of the visit that you'll be capturing the important things they say. When you're looking up information in the chart, narrate why you are doing so. You can even dictate in front of the patient, which helps to reinforce understanding.

• Don't feel bad about delegating. As a general rule, if a non-physician team member can do something, then they should do it. This frees you up for the things only you can do, and it shows respect for your team member's abilities.

• Don't feel bad about how full your in-basket is. Having an uncontrollable in-basket is bad enough on its own. Don't make it worse with excessive guilt about how far behind you are. Just get busy working on it.

BE HONEST ABOUT YOUR TIME, PRIORITIES, AND EHR SKILLS

It's common to think that you're more efficient than you actually are. But believing five minutes is enough to chart an encounter is unwise if it routinely takes you 10 minutes. If it takes you eight minutes to address diabetes, five minutes to address heart failure, and another 10 minutes to discuss goals of care, you will not have time in a 20-minute visit to address all of those issues, document the visit, and prepare for the next visit. Allowing tasks to run in excess of their allowed time leads to other tasks remaining unfinished at the end of the day.

Be honest about your personal priorities as well. Have you made it a priority to eliminate after-hours work? Imagine telling a loved one that you have to chart at home tonight because your patient needed more time to discuss another condition and you didn't want to make them come back for another appointment. The choice to spend extra time with patients is ultimately a choice to work after hours. For some, this is an acceptable trade-off. For others, it isn't.

Finally, be honest about your EHR skills. It's common for physicians to perceive the EHR as increasing their workload, yet many fail to take advantage of the EHR's efficiency-enhancing features. One study found that only 35% of physicians considered themselves proficient in EHR use, yet as little as two hours of personalized training can increase user confidence and efficiency.¹³ Advanced training workshops can lead to a daily reduction of 40 to 60 minutes per day of EHR use.¹⁴ No matter your career stage or level of training, you can benefit from deliberate practice and participation in EHR training opportunities.

LIGHTENING THE BURDEN

The U.S. health care industry transitioned to EHRs in the early 21st century, aiming to increase efficiency and make documentation less taxing. However, many physicians have found EHRs and their in-baskets to be burdensome rather than beneficial. While most physicians cannot avoid EHRs today, we can take steps to reduce the burden. If your documentation practices are inefficient, deliberate practice can help improve those skills. In addition, carve out time for documentation and other in-basket tasks during the workday, leverage your team, and consider other ways to maximize your efficiency and reduce “pajama time.” This will help make your clinical efforts more effective, more sustainable, and more personally fulfilling.