The EHR 'second shift' costs docs more than time: Try these expert-backed fixes to reduce inbox overload
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Doctors often think the inbox is one of the biggest problems in medicine, but the inbox usually isn't the starting point. The real issue begins during the visit. When the visit ends with unfinished work, work moves into messages. The inbox becomes a place where unfinished visits get completed.
—Ryan Stegink, MD, via Instagram
New problem? Flare of chronic problem? Request for a new med or test? Make an appointment, baby! Then, if you show up on time, I'll have at least 5 minutes for you v the zero millisecond I'm allotted for these messages.
—Family medicine physician @alwayswanttotakeanap via Reddit
EHR inboxes were designed to streamline care, but for many physicians, they’ve created a “second shift” that extends well beyond clinic hours.
As message volumes surge and responsibilities spill over from incomplete visits, clinicians are spending increasing amounts of time triaging notifications, often at the expense of focus, efficiency, and work-life balance.
As EHRs become the new normal across healthcare, physicians are increasingly bombarded with notifications via patient portals and inboxes. These notifications can include test results, referral responses, medication refill requisitions, and direct messages from clinicians and patients alike.[]
In some cases, physicians are receiving such large quantities of messages that it becomes harder to determine what’s truly important and what’s irrelevant, increasing the risk of overlooking abnormal test results.[]
"Doctors often think the inbox is one of the biggest problems in medicine, but the inbox usually isn't the starting point,” Ryan Stegink, MD, a pediatric physician, said in an Instagram Reel. “The real issue begins during the visit. When the visit ends with unfinished work, work moves into messages. The inbox becomes a place where unfinished visits get completed."
Related: AI scribes promised to reduce EHR burden—are they delivering?Clinicians spend an estimated 66.8 minutes per day on processing EHR notifications, which likely adds a substantial burden to their workday. Since a single notification often contains multiple data points, the actual burden and physicians' required cognitive effort is likely even greater.[]
For PCPs in particular, clinical practice has changed substantially in recent years to involve providing more care outside of scheduled appointments, driven in part by the rise in patient portal messaging.[]
Reducing inbox overload
The current state of the EHR is frequently cited by physicians as the most important stressor in patient care, and nearly 75% with burnout symptoms identify the EHR as a source.[]
"To reduce the burden of the inbox, we need to go upstream and reduce the number of messages coming into the inbox in the first place,” Christine Sinsky, MD, vice president of professional satisfaction at the American Medical Association, said during an AMA webinar. “And then to delegate much of the inbox work to upskill team members who can manage the majority of the inbox messages."[]
Patient interactions and work-life balance are negatively affected by the time requirements of EHR tasks during and after clinic hours. Patient portals and EHR messaging have created a separate source of patient care outside of face-to-face visits that is often not reimbursable.[]
"If you're an organization of 100 physicians with average rates of burnout and a very conservative estimate of the cost to replace that physician of $500,000, that organization is already spending almost $1.5 million a year replacing physicians who leave solely because of burnout,” Dr. Sinsky said. “You can reduce that turnover... by having more staff to help with activities such as the inbox."[]
Doc-recommended tips to relieve inbox burden
There are some strategies you can employ to better manage your inbox and reduce decision-making fatigue.
Consider these tips, culled from a lively discussion among physicians on Reddit:
"I'm not great at inbox yet, but I usually get myself down to 0 by the end of the work day... If I have to open a new 'order' encounter, [the patient] almost certainly needs an appointment. Questions that require more than 30 seconds of thinking that aren't a direct follow up from an appointment, needs OV. I never manage new (or old) medical problems through the portal." — Family medicine physician @Heterochromatix
"New problem? Flare of chronic problem? Request for a new med or test? Make an appointment, baby! Then, if you show up on time, I'll have at least 5 minutes for you v the zero millisecond I'm allotted for these messages." — Family medicine physician @alwayswanttotakeanap
"[We] have an NP whose role is essentially inbox management. In peds, there is a lot of extra pressure to get kids seen and taken care of promptly, and to be more forgiving of busy parents seeking the portal to access care... The NP manages provider inboxes, labs, triage calls, a variety of other miscellaneous items. Anything detailed/complicated that would typically be a visit, is either turned into a telehealth if appropriate or she works with our front office to get it added to the schedule." — Pediatrician @ForTheLoveOfPeanut
"Set a maximum weekly cap on how much you're willing to work for your current compensation, and simply don't exceed it... Decide what you'll prioritize in the time that you have - I usually do messages, followed by critical labs, followed by critical imaging, then everything else." — Family medicine physician @OnlyInAmerica01
"There are 2 levels of complexity for inbox messages... The MA can handle it... [or the patient] needs an appointment." — Family medicine physician @OllieWobbles