Brief
Patients have growing demands for digital healthcare experiences and continuous electronic access to clinicians. These demands overwhelm clinicians and raised a need for more standardized approach to the management of patient messages in the EHR. Our solution was to create a new ‘eProvider’ clinical role: a liaison for reimbursed digital clinical care and organizing indirect duplicate work within the EHR. Post-implementation survey results showed that patients and providers valued the protected time for digital work and wished to sustain this new role.
The Problem
The Electronic Health Record (EHR) has created substantial changes in the practice workflow of the primary care provider, both for direct and indirect patient care. Over the last decade, the expansion of patient health portals has been rapidly expanding. These portals are embedded in the EHR, allowing patients to interact with their healthcare team and securely view their health information. There is pressure directly from the health system and indirectly from patients to respond nearly immediately to patient messages.
Marketing this continuous access to clinicians has led to unintended consequences. The marketing of digitalized health sets unrealistic patient expectations for 24-hour per day, seven days per week access to their primary care provider. Consequently, patients send many inappropriate patient portal messages to providers and have inappropriate expectations for their management. For example, although the portal is not to be used for urgent matters, patients continue to use it for urgent health concerns. These messages can range widely in complexity from the very straightforward that can be managed by other staff (requiring no provider input) to the complex responses requiring a scheduled clinical encounter.
High expectations and complex needs increase the messages sent and perpetuate a burnout cycle. Providers can only complete some patient treatment, patient encounter notes, other EHR duties, and digital communications during scheduled business hours. Hence, they spend their evening and weekend off-hours responding to patient portal messages to keep up with health system pressures. Off-hours responses reinforce patients’ expectations of continuous access to clinicians. Additionally, message volume for providers has increased over time, often resulting in increased indirect unreimbursed patient care work. This work is often done during the provider’s ‘free time’ and can lead to increased burnout.
We needed more standardization in managing patient portal messages.
Our Solution
Our solution was to create a new ‘eProvider’ clinical role: a liaison for reimbursed digital clinical care and organizing indirect duplicate work within the EHR. The eProvider (eP) would address patient portal messages using a novel workflow without additional hiring. The Duke Institute for Health Innovation (DIHI) funded staff and provider time to create this clinical innovation.
THE PROCESS
We recruited ePs from among our faculty, developed a schedule distinguishing their digital from in-person time, and incorporated this among the department’s electronic scheduling templates. We trained nurses and allocated a portion of their time toward determining whether patient concerns are appropriate for a video visit with a designated provider. We worked with patient access employees to train them to convert the nurses’ designations for eP need into eP virtual visits. We centralized faculty and staff personnel and schedules so they could spend daylight hours responding to patients’ digital needs. Finally, we kicked off eP care in July 2022 and have sustained it.
Impact
We asked patients for verbal feedback via the message portal system, and we surveyed physicians about EHR time and burnout. Patients reported satisfaction with getting needed meds promptly via the patient portal. Providers were pleased. Surveys captured that provider hours managing patient advice request messages per clinical day for patients went down from 1.91 to 1.50 hours per day. We asked providers how many additional daily hours they would need to feel like clinical care and patient-digital-response work were complete. This count decreased from 2.72 to 2.13 hours from baseline to pilot end. Providers across the department, not just ePs, felt they gained 49 minutes daily due to optimizing Patient Advice Requests.
ACADEMIC IMPACT
Presentation at a national conference, STFM Annual Spring Conference 2023
UPDATE – 2024
The project clinical lead is involved in the MyChart Task Force and other work groups across Duke Health, looking at the best ways to implement this solution in different fields and specialties of medicine.
