Physicians are drowning in paperwork, messages, EHR tasks, and other administrative responsibilities. One study found that for every hour physicians spend providing direct clinical face time with patients, they spend nearly two hours on EHR and desk work during the clinic day.¹ After clinic, physicians spend one to two hours doing additional computer and other clerical work (dubbed “work after clinic”).¹

Systemic changes are needed to help reduce physicians' administrative burden and address “system-induced distress,”² but in the meantime there are steps physicians can take to reduce the amount of time we spend on these tasks. This article shares 10 practical tips for one of our biggest time wasters — the EHR inbox.

1. DELEGATE MESSAGES WHEN POSSIBLE

The default in many EHR systems is for all messages to go directly to the physician, but this is inefficient. Ask your IT staff to set up your system so it routes messages to the appropriate person, such as your medical assistant (MA) or nurse, and then have your staff do all they can before getting you involved. The goal is for you to do only the tasks that require your expertise and to delegate the rest.

When your input is needed, teach staff to take in-depth messages so that you will have the information you need to reply effectively. You can make templates for this. For example, “When someone calls with urinary symptoms, ask them to specify duration of symptoms and, if they have dysuria, urinary frequency, fever, back pain in kidney area, or chance of pregnancy.”

If a message involves an issue that will take a lot of time, instruct your staff to schedule the patient for an in-person or telehealth visit. That way, you will get reimbursed for your work and it will take up a spot in your work schedule as opposed to a spot in your personal schedule after work hours.

2. HAVE YOUR STAFF FILL OUT FORMS

Staff may not be able to complete forms entirely, but they can at least get them started for you. For example, your MA can fill out several parts of disability and physical forms — office address, date, patient name, chart number, first and last visit, etc. If you need to do a lot of work on a form, try to do it during an in-person or telehealth visit.

To handle prior authorizations, have one staff member specialize in this or train several MAs to deal with them. An experienced MA can usually fill out the form and ask you just a couple questions. (Questions are an opportunity to teach.) At times you may find that, instead of going through the authorization process for an expensive medication, it may be better to direct the patient to resources such as GoodRx.com, which may be less expensive than using their insurance for certain drugs (e.g., sildenafil). You could also try CoverMyMeds.com.

3. DISCUSS TEST RESULTS AT VISITS WHEN POSSIBLE

Communicating test results in a timely manner is vital, but there are ways to make the process more efficient.

• At the current visit, order labs to be done before the next visit. This ensures that you will have the results back and be able to discuss them with the patient at the next visit, which eliminates the need for messaging between visits.

• Have a holding area in your EHR for results that can wait until the patient's next appointment.

• Consider using a pre-visit lab testing protocol (see https://edhub.ama-assn.org/steps-forward/module/2702697) that prompts staff to schedule the next appointment for the patient, enter orders for needed lab tests, and follow up to ensure their completion before the next visit.

4. HAVE PROTOCOLS FOR EMERGENT AND URGENT MESSAGES

You can be a little more relaxed with your inbox management if you know that emergent and urgent issues will not be missed. Setting up a protocol ahead of time for this can help clarify expectations. For example, staff should be told not to just leave a message in the EHR for urgent or emergent issues, but also to do the following:

• For emergencies, immediately interrupt you or your triage nurse,

• For urgent situations, leave a note on your computer, chair, or desk that will not be missed when you return to your office between visits.

If you have a triage nurse, forward appropriate messages to that person. A good nurse can help determine if a patient can wait for a visit, can be sent to urgent care, or should go to the emergency room.

5. QUICKLY REVIEW YOUR INBOX BEFORE YOUR STAFF LEAVES

Most doctors work later than their staff. It can be frustrating to see a group of messages that your staff could have handled if they hadn't already left for the day, forcing you to personally make a bunch of additional phone calls. To prevent this, spend a few minutes quickly reviewing your inbox 30 minutes before your staff leaves and forwarding messages or results with instructions. Because you're only doing a quick review, you may need to go back into your inbox later and respond to the rest of the issues. You can redesignate those messages as new messages to help you remember which ones need your attention.

6. USE TEMPLATES FOR RESULTS

When communicating test results for common issues, instead of writing new messages each time, use templates that you can modify as needed. Depending on the issue, the information can be sent straight to the patient (electronically or by mail), sent to your staff to discuss with the patient, or both. Here are some examples:

• Osteopenia: Your bone density is somewhat low. I recommend regular weight-bearing exercise, and adequate vitamin D and calcium intake.

• Prediabetes: Your glucose is somewhat high, so please get aerobic exercise, eat at least five servings of vegetables a day, and avoid refined carbohydrates (including regular soda, fruit juice, foods with added sugar, white bread, and white rice).

• Hyperkalemia: Advise patient these labs are OK except potassium is a little high. The potassium level is very sensitive to how the blood is handled, so it can often be artificially elevated. However, if it is truly elevated, it can cause significant problems, so please explain this and ask the patient to recheck potassium blood test over the next week. The test does not have to be fasting. An order will be waiting at the lab for the patient.

• Nasal staph: Please advise the patient that there is staph bacteria in the nose. In order to reduce risk of surgical infection, please ask the patient to do the following starting the week before surgery: 1) Use the mupirocin ointment in each nostril twice a day for five days, and 2) Also for those five days, once a day in the shower apply chlorhexidine soap from the neck down and wash it off after 10 minutes.

(More templates can be copied or modified from StressRemedy.com.)

7. LIMIT YOUR KEYSTROKES

How many times per day do you type in your ID or password? One way to reduce this number is to have a badge reader on your computer that automatically logs you in. Badge readers can also serve as finger-print readers to facilitate the electronic prescribing of controlled medications. Another solution is to talk to your administrative or IT staff about changing the login requirements, for example, to stop requiring a password for every prescription. It is understandable to require a password for controlled substances, but requiring it for every prescription is cumbersome.

Another way to limit unnecessary keystrokes is to leverage your EHR. Some EHRs allow you to send common messages to staff with one click, for instance, “needs visit” or “needs to do labs.” If you have an IT staff, work with them to identify additional ways to limit keystrokes on your repetitive tasks.

8. STREAMLINE REFILLS

Prescription refills can be a tremendous burden for physicians, but there are some ways to lighten this workload. For most prescriptions you write, check at the current visit to see whether the patient has enough refills to last until the next visit or next physical. Consider a 30-day supply with 12 refills or a 90-day supply with four refills for most medications, as this will reduce refill requests. (This may not be appropriate for certain patients or certain medications, such as controlled substances.)

Set up a refill protocol so that staff are authorized to make appropriate refills that you can co-sign. Per the American Medical Association's Steps Forward module “EHR In-Basket Restructuring for Improved Efficiency” (https://edhub.ama-assn.org/steps-forward/module/2702694), “If the request is appropriate and the patient is not due for an appointment, your team should be able to fill these requests per protocol so the patient has enough medication to get by until his or her next visit. If the patient is due for an appointment, your team should be able to refill the medication for 30 days while making sure that a visit is scheduled within that time period.”

Here are some examples of staff protocols for several common refills:

• Statins: Refill if visit within a year and AST, ALT, and lipid panel are in normal range within a year,

• Levothyroxine: Refill if normal TSH and visit within a year,

• Blood pressure (BP) medication: Refill if BP in range and visit within six months,

• ACE/ARB: Refill if BP medication protocol followed and basic or complete metabolic panel within a year.

For refills without a protocol, teach staff to fill out requests completely before they get to you with their best educated guess as to how many refills are needed until the next appointment. They should also include the dates of the last and next visits on the request, which will save you several clicks. Again, if possible, use one-click technology or templates to send messages to staff to set up patient labs, a visit, a physical, etc.

9. REMEMBER MACRA STARTS WITH MA

Your MA or nurse can assist with numerous EHR tasks that will help you close care gaps and meet quality performance metrics. This can also help you provide more proactive vs. reactive care, which can make your workday feel less chaotic. For example, your MA can “tee up” orders for health maintenance tests or flu shots so they're ready for you to review when you enter the exam room, follow up with patients to check that tests were completed, and perform other patient outreach or population management tasks through your EHR.

10. PRIORITIZE A REASONABLE SCHEDULE

If the source of your inbox overload is that your schedule is too full, you need to set some limits. You may feel that you have no control over your schedule, but you do have some leverage. The primary care shortage is anticipated to get worse, and replacing a family doctor can cost about half a million dollars.³ Don't be afraid to politely and assertively ask your employer for changes that will make your job more doable and satisfying. Here are some issues to consider:

• How many of what types of visits should be allowed in your schedule?

• How can you have some autonomy over your schedule?

• If you are paid based on productivity, are you coding fully and accurately?

• Are you modeling healthy work-life balance for your patients and colleagues?

• Do you have trouble saying “no”? Every “yes” to more work takes time away from family and friends.

BONUS TIP: ASK FOR HELP

Trying to do everything yourself is a recipe for failure. Avoid the traps of pride and perfectionism, and ask for help when you need it. Getting help and working through challenges makes us more empathetic and compassionate, and better caregivers and people. Sources for help could be an EHR super user, a colleague, your primary care physician, a counselor, or an employee assistance program. With the availability of televisits, getting help is more convenient than ever. Consider resources such as PhysicianSupportLine.com or Care4CaregiversNow.org as well. Getting help is a sign of professional maturity and wisdom. Don't wait until you're at wit's end. Seek help early and often.