Physicians have longed for electronic health record systems that could share information across networks.
But as their dreams are being fulfilled, a new problem has emerged—inbox overload. And that burden is causing physician burnout, patient-safety issues and the need for new innovation to help triage the most urgent messages.
Researchers in Texas recently gauged the gush of e-mails and counted more than 276,200 message notifications that flooded the EHRs of 92 physicians in three group practices over 125 workdays.
Their results were recently published in a JAMA research letter called “The Burden of Inbox Notifications in Commercial Electronic Health Records.”
Primary-care physicians—half of the group studied—received on average 77 notifications a day, the researchers reported. About 1 in 5 notifications (20.2%) were related to test results, including lab, imaging, pathology, pulmonary function, EKG, stress and other tests.
Specialists had fewer than half that number, 29 notifications a day, but a higher percentage (35.7%) were for test results. Some of those, such as the results of panels of metabolic tests, contain seven to 14 lab values, which impose greater cognitive burdens on physicians than other messages, the researchers noted.
Based on earlier studies at the Veterans Health Administration that found clinicians spent on average 52 seconds per EHR notification, the Texas researchers extrapolated that the PCPs in the study, on average, spent about an hour and seven minutes a day processing their messages.
The researchers concluded that what's needed is a multi-pronged approach to handle the information deluge, including “strategies to help filter messages relevant to high-quality care, EHR designs that support team-based care, and staffing models that assist physician in managing this influx of information.”
“There's a lot more of a variety of messages in the EHRs than we expected,” said Dr. Daniel Murphy, corresponding author of the study, assistant professor of medicine at the Baylor College of Medicine and a researcher at the Center for Innovations in Quality, Effectiveness and Safety. "We don't really know if they impact care in a meaningful way or just take up providers' time.”
With some messages, such as those imparting lab test results, their clinical impact is obvious, but others are “less proven,” Murphy said. Some are from specialists, merely confirming a referral was scheduled, or pharmacists, saying a prescription refill was requested.
The three clinics used EHRs from either Epic Systems or GE Healthcare (Centricity). Neither did a notably better job than the other at handling the messaging traffic, Murphy said.
Fellow researcher Hardeep Singh, chief of health policy, quality and informatics at the Michael E. DeBakey Veterans Affairs Medical Center, foresees “more and more communication” between primary-care providers, specialists, nurses, labs, pharmacies and patients. One problem is that the physician's EHR is "not designed for team-based care," he said.
Singh said that while interoperability is a good thing, he's worried about how a flood of messages could cause physician burnout and negatively affect patient safety.
In a 2013 JAMA report by Singh and others, based on a survey of 2,590 primary-care physicians at the VA, nearly 70% reported receiving “more alerts than they could effectively manage” while almost 30% reported “having personally missed results" that led to delays in care.
Vic Arnold, national leader for the physician solutions practice at Huron Healthcare, a Chicago-based consulting firm, wasn't surprised by the volume of messages in the latest study.
“If anything, it seems a little low,” Arnold said, adding that he's on the lookout for better health IT tools.
Some EHRs can pluck out and add electronic decision support to discrete data elements in incoming messages. But, by and large, users of the IT systems still must rely on human judgment in triaging most messages, Arnold said.
Meanwhile, the types of messages and their volumes are changing because of to payment reform, he said.
The problem with inbox overload predates the movement toward consumer-based healthcare and patient engagement, but they make the problem worse, Arnold said. For now, direct e-mail exchanges between providers and patients are limited because of privacy issues and consumers' limited use of encrypted e-mail. But many messages are being routed through secure patient portals built into provider's EHRs.
“Where we see people doing the smart thing, you have a clinical administrative assistant who will follow up and say, 'We want to respond to your issue,' ” Arnold said. “I see a lot of people doing (that). Technically, they'll have the ability to update a medial record, depending on the state” and their licensing laws.
They'll push some messages to a nurse or a nurse practitioner, or LPNs in some places and then to a physician only if need be, he said.
All this work and time points to a need for physician compensation reform, said Dr. Steven Waldren, director of the Alliance for eHealth Innovation at the American Academy of Family Physicians.
Walden said it's another reason why fee-for-service reimbursement just doesn't line up. ”Physicians should be compensated for care coordination," he added.
He said more research needs to be done to assess messaging and its impacts so that technology can adapt to help solve the problem.
Fellow EHR researcher Ross Koppel said Murphy and Singh's research "provides a better view of the double-edged sword of our wonderful but often vexing technologies.”
“More messages do not often translate to more knowledge or faster communications,” Koppel said. “Stuff gets lost or missed.”
