Strategies to Alleviate Inbox Burdens Erupting During COVID-19

By Kim Pittenger, MD
Director, Lean Health Care Practice
Moss Adams

Original Publish Date: May 11, 2021

Health care management is increasingly complex during the COVID-19 pandemic with many challenges expected to remain as it subsides—in particular, increased inbox volumes as virtual care expands with burnout also on the rise.

External pressures in the market and industry pile on as internal compulsions for productivity and time management amass at a fever pitch; despite promises for efficiency, electronic heath record (EHR) tools can add to administrative burden. Burnout is at epidemic rates, and however well-intentioned, wellness initiatives often manage symptoms but leave root causes untreated.

Fortunately, lean methodologies can help providers in ambulatory practice regain control of days, complete work, and return home on time—while still delivering excellent care and a sense of professional satisfaction.

Transform Your Practice Through Daily Habits

Take a targeted approach to transform how you practice ambulatory care by moving away from the behaviors of batch and into flow.

Batch production is when tasks pile up; flow references the act of tackling tasks in small manageable lots throughout the day.

This transition involves thinking of care delivery in an entirely new way: not in terms of provider-patient transactions but instead in terms of a flow cell—an arrangement of team members, time, technology, supplies, and treatments that work together to produce service and care without waiting between handoffs.

What Can You Expect When Moving from Batch to Flow?

Moving from batch to flow can help remove waste from your practice—which can ultimately help free up time for things that matter most in medicine: improved quality of care and healthy providers who can sustain a fulfilling practice.

It’s not about working more or harder; it’s about reclaiming tasks, processes, and time so your team functions efficiently at its highest level.

Potential benefits from moving from batch to flow can include:

A day that involves teamwork with a trusted and well-trained dyad partner in each medical assistant (MA)
Smooth transitions between patients
A clear inbox with tasks clearly assigned
In-person and virtual visits set up in advance
Clear and concise notes and documentation written and closed efficiently
Steady pace of work throughout the day that doesn’t feel increasingly rushed or depleted as the afternoon descends
The ability to go home on time and not take work home for evening catch-up

Example

For example, consider Dr. B and Dr. F who were medical group colleagues.

Dr. B had an average of 65 items left in her inbox every day, so she caught up in the evening between stints of helping her children with homework. She resolved some notes before coming home but many remained, which she handled after her kids were put to bed. The next morning, before her visits, she completed another 10 inbox items, which got her off to a late start. Throughout the day, her inbox piled up once again.

Dr. F, however, committed to moving from batch to flow. At the end of each nine-hour workday, she only had three unfinished phone tag items in her inbox—and these were because she wanted to reach out to patients directly.

The following morning before her first visit, she huddled with her MA for 15 minutes, set agenda targets, signed protocol orders, built problem lists that loaded into notes, and set up shared decision-making tools.

Together, she and her MA signed Family and Medical Leave Act (FMLA) forms and reported a few labs before diving into the first visit. Between easy and complex patients, Dr. F’s medical assistant set up two to three inbox items; together, they used three inbox pauses per day to keep apace of the normal 50-70 items per day.

They also reduced the documentation time for moderately complex visits—coded as 99214 with detailed history, detailed exam, and moderately complex decision-making—by using voice recognition and concentrating on decision making text in the assessment, each done in three to four minutes.

A friend had also shown her that notes composed hours after a visit—in batch—were 15%-30% longer without improved quality of content.

How Are Lean Strategies Used for Improvement?

These five lean strategies can help you implement a transition from batch to flow.

1. Adapt a “Don’t Just Work; Stand There” Mindset

Lean teaches critical thinking and problems solving so that you slow down to speed up.

By pausing and reconsidering the way you work, you can eventually transition to a state where you can do the work that matters.

Critical thinking and root cause analysis can enable you to consider deeply the flaws and defects in your current processes and imagine how to improve them.

2. Go to Gemba

Gemba is the shop or practice floor, the place where the actual work is done. Going to the gemba to see operations firsthand is always a priority in lean methodologies.

Watch each step of the care process objectively to see how it relates to the next. Observe areas of value and efficiency, as well as waste and defects.

3. Create Value Stream Maps

Once you visit the gemba, you’re ready to map your care process. Draw out every step, then time each one and the spaces in between.

Afterward, imagine your ideal future state—and map what that would look like. Conducting a gap analysis will then help you determine what you need to do to move from your current to future state.

4. Conduct Improvement Events

Once you articulate problems, create countermeasures and test solutions.

Set metrics for success. Perform small experiments to find the best solutions.

5. Write Standard Work

Document those effective practices so you can operationalize your new solutions.

Keep improving and make those your new practices.

What Options Are Available to Fast-Track Solutions?

Lean is an improvement methodology that can help every aspect of your work—and can guide you as you move from batch to flow.

Transitioning these specific challenges from batch to flow can help fast-track solutions.

1. Create Provider-MA Dyads That Include Colocation and Huddles

Establishing a shoulder-to-shoulder dyad can help enhance workspace and collaboration, leveling the load of work.

The MA effectively becomes the provider’s flow manager throughout the day, a relationship that depends on trust and training. With proper precautions, this can still be achieved successfully during the COVID-19 pandemic.

In huddles, the provider-MA dyads:

Go down the schedule list to add items
Select visit note templates
Set up orders to complete tasks
Prepare for contingencies

The dyad helps ensure that visit work is assigned to the right care team member and makes time and space to complete non-visit work as well.

2. External Setup

Collaborate with your MA to conduct prep for standard parts of the day—huddles, rooming, face-to-face and virtual visits, and between-visit work.

Once empowered, MAs can scrub charts for complex patients who need extra time and special care—whether for mobility, clinical complexity, or extra teaming with a nurse care manager, MSW or pharmacist.

Tasks that can then be completed through standard work by an MA or nurse before the start of the visits include:

The EMR health maintenance module, programmed to display needed interventions and recognize annual wellness visit due dates
Rooming, completed just-in-time
Protocols that enable MAs to tee up orders for the provider or nurses to order common tests and vaccines

3. 5S the Inbox

Despite promised efficiency of the EHR, the inbox is now among the most clogged aspects of practice, on average with 60-80 items. The inbox is no longer a mix of clinically important messages but has become a collection of irrelevant algorithm-generated items and potentially annoying notes.

Rather than let inbox clutter run your day, organize your workspace with 5S. 5S stands for sort, set in order, shine, standardize, and sustain.

Begin with a deep dive into the contents of your inbox and ask the hard questions:

How many of each type of item—secure messages from patients, results to analyze and reports, pharmacy requests, shared patient information—do you receive?
How long do these items take to complete?
How many are unactionable or inappropriate for the provider?
What’s your turnaround time?
Do you use free text or smart phases in message responses and lab reporting?

Then, take the following actions:

Sort messages to understand which are shallow and quick; which need more time for thinking and chart research; which can be completed between patients, and which can be distributed to relevant team members
Set in order messages so that every member of the team helps with inbox messages per top-of-license assignments to free the inbox of irrelevant algorithm-driven messages
Shine so that messages are assigned to top-of-license roles and are automated with smart-phrases as appropriate
Standardize rules for the inbox and train to those rules; use response templates for common requests and update these as needed
Sustain with training and group consensus about strategic practices between provider and MA

4. Improve Your Notes and Documentation

Notes and documentation are the provider’s responsibility, so it’s important to be confident you’re working at the top of your game and meeting the updated evaluation and management (E&M) rules.

Concentrate text on decision making in the assessment. Take advantage of the 2021 E&M rules. A typical three-problem 99214 note should take a maximum of three to four minutes.

Ask yourself the hard questions first, including:

Do you over-document, cut and paste, and demonstrate so-called note bloat?
Do you type—and if so, in front of the patient? Very few doctors are fast and accurate—are you?
Are you using voice recognition—with its ever-improving capability to save time—over typing?
Do your notes for common conditions and encounters have consistent format and complete content for plans and cross coverage?
Do notes meet coding standards?
When do you complete and close notes?

After assessing these questions, you can get to work. Enlist technical help as you consider voice recognition software, train on coding, and use automation to affix orders. Seek feedback from a peer whom you trust to be honest to gauge if your notes are clear and useful for cross-coverage.

Work with your MA to load diagnoses for visits. Work with your informaticists to enable smart templates that autopopulate diagnoses in the Assessment and Plan area of a note.

Finally, focus on self-improvement as you sharpen your language, adhere to a consistent format, and set goals and metrics to close notes.

We’re Here to Help

To learn more about how moving from batch to flow can help provide more control over your time and outcomes, contact your Moss Adams professional.

Additional Resources

For regulatory updates, strategies to help cope with subsequent risk, and possible steps to bolster your workforce and organization, please see the following resources:

Kim began his career in family medicine in 1979. By 2004, he became a strong believer in the Toyota Production System and its ability to improve the ease of delivering quality care and contribute to financial success. He can be reached at (206) 302-6430 or kim.pittenger@mossadams.com.