The pieces weren’t fitting together. My 2:00 p.m. patient had just described a confusing constellation of symptoms and a vague temporal profile; lacking an obvious diagnostic pivot point, I ordered basic labs and promised to follow-up soon. I hoped that taking 5 minutes to organize my thoughts while putting together the clinical note could offer some structure to my evolving diagnostic framework. As I logged on to my computer and opened the electronic health record (EHR), there it was… again. In bright red font, an upward arrow indicating a “high priority” patient message next to a bold number 4, informing me of the number of new messages I had been assigned to address, but hadn’t yet reviewed. The attention switch was unavoidable. What if someone was dying? What if I really screwed something up? After clicking into the message, I learned a patient was asking for an urgent refill of their antibiotics, yet the single line of clinical information was insufficient to judge the best course of action. 15 minutes later, following a clarifying phone call to the patient, a phone note rendered, and a prescription sent, I was able to hit the done button on the message. A quick view of my schedule informed me that my 2:30 p.m. patient has been waiting for me for 15 minutes and my 3:00 patient is well into the process of being roomed. My motivation to think deeply about my puzzling patient lost, I move on and focus on the next patient. I finish the day, go home, have dinner with the family. I help put the kids to bed and log on to the computer at 8:30 pm. I stare at the in basket. The vague unease and resentment I felt last night quickly seeps back in. Tomorrow, I promise, I will leave with all my work done.

William Osler extolled us to “cultivate the power of concentration, which grows with its exercise”.1 Piecing together complex and disjointed information, creating a coherent patient narrative while integrating the unique psychosocial identities of the patient into clinical decision-making demands focus, attention, and clarity of thought. Internal medicine, at its best, enables accessible, high-quality, patient-centered care with timely and accurate diagnoses, cost-effective evaluation and management, and improved health outcomes for patients entrusting their health care to us.2 Reliable, clear, and manageable non-visit care (NVC) workflows are not only important for effectively executing the cognitively demanding work necessary for patient care, but they are also necessary for the physician’s physical, social, and emotional well-being.3,4 The unpredictable flow of non-patient facing work and low levels of control over clinical work are well-recognized contributors to burnout among primary care physicians.5,6

In-basket message volumes have increased in many health care systems since the start of the COVID-19 pandemic,7,8 with time spent on in-basket work higher for female physicians, and those caring for older and sicker patients.9,10,11 Asynchronous, electronic patient care remains undervalued in modern primary care practice. The time allocated for answering these messages is inadequate, nor purposefully supported by the care team in a way that optimizes the clinician’s role in the process.12,13,14,15

The development of asynchronous, directly pushed, electronic NVC has created an unrelenting conveyer belt of unscheduled and reactive messages seen in many primary care practices. Electronically routed NVC tasks do not require delivery from a trusted team member, and can instead be sent on by employees who may have never met the physician or the patient being cared for.13 These unscheduled tasks are relegated to time that does not exist on the physician’s calendar, with other team members unaware of how, when, or where the physician would complete these tasks. The physician, nurse, or administrative staff member may be drowning in messages while their fellow care team members remain busy and unaware, separately sequestered in their own electronic world.

While professional ethics dictate that physicians sacrifice themselves to meet a patient’s needs,16 there is always a breaking point. How many messages with inadequate information, unclear patient expectations, or assigned tasks below their skill level can be sent to the frantically busy primary care physician before that breaking point arrives? That breaking point may result in cutting back clinical FTE, seeking administrative or non-primary care clinical responsibilities, or leaving primary care to reinvent one’s career. We can and must do better. And better is possible.

What Does the Literature Say?

There is a growing body of literature discussing the challenges posed by electronic in-baskets and potential steps for improvement. A thematically organized summary of selected recent literature is described in Table 1. A recent call to action from subject matter experts on primary care transformation translates this literature base into steps which health care systems, payors, and regulators can take to begin addressing NVC overload.17 While these prescriptions are well reasoned, physician leaders and their administrative partners looking for actionable and feasible solutions may find the recommendations daunting and wonder where to begin. Herein, we propose a conceptual framework for NVC that primary care physician leaders and their administrative partners can leverage to develop a more intentional, balanced, and adaptive system of NVC (Table 2).

Table 1 Summary of selected NVC literature and recommendations for improvement
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Table 2 Intentional and adaptive vs. chaotic NVC systems
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A Better Path Forward: the Adaptive NVC System

Our conceptual framework begins with analogizing the flow of NVC tasks to 4 sequential factors influencing the flow of water through a river: (1) the inputs of tasks entering the NVC system, corresponding to the volume of water entering the main river from its tributaries; (2) the specific direction, sequence, and assigned team members that the NVC tasks flow to, corresponding to the course the riverbed follows to reach its destination; (3) the EHR interface of tasks and communications, corresponding to the rocks, islands, and other obstacles found within the riverbed; and (4) the effectiveness of the primary care team in moving NVC work forward, corresponding to the contours of the riverbed, which determine the rate of flow. As NVC tasks move through a system of work, task completion is impacted by the volume and complexity of tasks entering the system, the specific pathway assigned NVC tasks follow to completion, the structural features and obstacles which disrupt planned workflows, and the effectiveness with which primary care teams complete their assigned work. The river flow analogy allows us to visualize the multitude of factors impacting not only NVC completion, but the burden (water turbulence) and collateral damage (erosion) that poorly executed NVC tasks have on the primary care system broadly, and the primary care physician in particular.

If the NVC system has too many tasks entering, if the workflows or EHR processes impede efficient completion of the work, or if the front-line team functions ineffectively, the NVC work will overwhelm the underlying system and the people within it. Just as a river system adapts to changes in precipitation or habitat around its watershed, the primary care practice must adapt its systems of work to changing patient needs and variable primary care resources. To move towards a system with a more balanced and steady flow of NVC work, we propose that the management of NVC work should be targeted towards the following four domains: controlling NVC inputs, defining NVC workflows, improving the EHR interface, and optimizing primary care team effectiveness.

Managing the NVC Tributaries or Controlling NVC Inputs

The selection of tasks which flow into the primary care team’s NVC work system, or the process by which patient requests are transferred from an intake point to the primary care team’s established workflows, is a critical step in calibrating the volume and content of NVC work to the primary care team’s capacity and skillsets. The entry of NVC tasks not only determines the volume of NVC work entering the system, but also defines the content of the daily work of the primary care team. Indistinct boundaries surrounding the work of the primary care team, including lack of clarity on which team member should be assigned a particular task and how that assigned work should be completed, are important contributors to primary care physician dissatisfaction.18 The creation of structured and transparent NVC processes presents an opportunity for primary care physician leaders and their administrative partners to seek input and provide clarification on which tasks should be done by the front-line primary care team and which tasks can be delegated to non-primary care team support staff, as well as whether that work should be completed through visit (traditional or telemedicine) or NVC workflows. Common requests which should and should not enter the primary care team NVC system must be clearly established by the practice, and the best way for patients to make common requests needs to be consistently communicated to both team members and patients. Table 3 provides hypothetical examples of common patient requests that could be considered for entry into the primary care team’s NVC system.

Table 3 Hypothetical dispositions for common patient requests
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Defining NVC Workflows

The workflow an NVC task follows before reaching its endpoint is where the selected NVC task is clarified, necessary information is added to the request as appropriate, and the task is routed to the most appropriate team member who has a clear understanding of their role in completing this task. Robust workflows in this part of the system are the backbone of a well-managed NVC system. HealthPartners Medical Group in St. Paul, MN,19 after comprehensive restructuring of in-basket folders and redefining team member roles, specified and reengineered in-basket workflows, achieving significant improvements in physician efficiency and satisfaction. Clearly defining workflows for common NVC tasks was felt to be foundational for the improvements observed. The lesson from this work is that once well-designed and clear workflows are established, common tasks can be completed with a reasonable level of variation and improved efficiency when outcomes such as message turn-around time, communication quality, and patient experience are evaluated.

Improving the EHR Interface

Primary care physician leaders and their administrative partners should also address EHR features which create turbulence in NVC workflows. Redesigning the EHR to improve user experience can yield significant improvements in NVC efficiency and physician wellness.20,21 At the University of Colorado, real-time redesign of the EHR interface resulted in improved end-user experience. During brief and focused periods of time, team members, informatics leaders, and process engineers conducted “EHR sprints” consisting of EHR training, user customization, and real-time EHR interface redesign, collectively resulting in significant improvements in end-user satisfaction.21 For practices that are just getting started, simple EHR optimizations such as reducing the number of in-basket categories and removing automated notifications and unnecessary tasks can significantly improve the cognitive burden 22 faced by front-line team members. EHR training, protected time for EHR personalization, and “at the elbow” support to improve user efficiency may also be important adjuncts to reducing this turbulence created in the EHR interface.21

Optimizing the Effectiveness of the Primary Care Team

Successful and sustainable NVC systems require high-functioning primary care teams. Trust among team members, predicated on team members trusting their colleagues to accurately and reliably identify the patient’s need and the urgency for action, serves as an important elixir to the angst provoked by messages arriving in the in-basket with uncertain expected actions and prioritization. The principles that make this team trust possible, and on which high-functioning primary care teams rely, have been previously outlined 23,24 and include promoting shared decision-making among team members, fostering effective interprofessional communication, learning from failure, and creating organizational structures that support multidisciplinary teamwork. For example, a primary care practice at Bellin Health in Wisconsin redesigned care team roles and processes alongside systematic efforts at cultural change and team building resulting in dramatically expanded primary care team capacity.25,26

Finding a Place to Start

Primary care physician leaders and their administrative partners, recognizing the challenge of developing better systems for managing NVC workflows, need not “conquer the in-basket,” but should instead seek to make iterative and continuous improvements to existing NVC systems. Individual leaders will need to focus improvement efforts differently based on their patient population’s needs, clinic resources, and electronic and regulatory environments. Primary care practices which have successfully improved NVC systems have done so by considering the design of the entire NVC system and by clearly identifying the optimal roles and workflows for each care team member.19,25,27 A logical starting point is to ask team members which NVC processes most contribute to team frustration. Involving ancillary and non-clinician staff such as medical assistants, nursing team members, scheduling staff and medical administrative assistants in the redesign will be critical for these staff to maximally utilize their professional skills and optimally contribute to the work of the high-functioning primary care team.

Conclusion

In the modern primary care practice, the evolution of unstructured systems of NVC poses significant challenges to the work experience of primary care physicians and team members. Developing trusted systems for managing NVC, where tasks are intentionally and clearly selected for NVC completion, where selected tasks default to mutually agreed upon, reliable workflows, and where those workflows are executed by a high-functioning primary care team, will significantly improve the experience of the NVC work that makes up a substantial part of the work-life of contemporary primary care teams. Success in these systems is dependent on front-line team member engagement, role clarity, task clarity, and building trusting relationships among team members. While redesigning these processes may appear onerous and costly when compared with continuing the status quo of reactive and ad hoc systems of electronic work, the rewards of diminished frustration, enhanced team member relationships and connection, and better patient care are not only worth the effort, but necessary for the primary care clinic to remain a place where physicians want to continue to work and thrive for the duration of their careers.