The pandemic, patient messages and phone calls: Octopus or Starfish?

Here we are 19+ months into the pandemic. Time to look at our (unvalidated) trends within our 12 hospital, 1000 clinic health system in Colorado.

Top (blue) line indicates outpatient visit volume monthly from Sept 2019 through Sept 2021. Over 2 years, we saw that dramatic dip in volume in March. That was followed by a gradual recovery and a 10% sustained increase in volume since then. We have added some clinics to our system in the meantime.

Magenta line indicates online messages. We started at 58,000 monthly messages in September 2019, and have sustained 180,000 messages in the most recent 3 months of 2021, a 3 fold increase in patient messaging. OK to ignore that weird peak in Mar 2021, related to a one time system broadcast. This is a real concern for provider workload.

Orange: Surprisingly, we also see an increase in telephone messages (triage-type phone calls): from 23,000 to 35,000, a 1.5 x increase. This means that online messages have NOT replaced phone calls since the onset of the pandemic. This could be related to the growth in percentage of our patients who now have a portal account (growth from 70% to 85% of our patients enrolled in a portal account, over 1.6 million accounts), as well as existing portal-using patients sending more requests and messages, wanting to avoid in-person visits.

Red: Additionally, Scheduled Phone Calls (non-existent prior to pandemic) are now at 5000 monthly messages, and

Green: video (virtual) visits went from nearly zero, up to a peak of 70,000 a month, then stabilizing at 23,000 monthly.

It is an interesting, evolving picture. We have not formally changed staffing or workflow to accommodate this change in message and visit volume, and it has resulted in a massive increase in inbasket messages for providers and staff, with concerns of an unmanageable burden and real risks of burnout for providers and clinical staff.

We believe that, at its root, patients want care, are more anxious about their health during a pandemic, want to avoid in-person visits, have learned about our online tools, and are unclear as to the best way to interact with us.

We could: improve our “front door” experience “Here is how best to contact and work with us”. We could improve our triaging of incoming messages to find the right location/time/place (online message, eVisit by messaging, online chat, scheduled phone call, virtual visit, urgent care, emergency department, other innovative approach).

We could ensure our teams know the best practice for: handling patient questions, prescription renewals, referral requests, outreach programs, remote monitoring, when to suggest video or phone visits, huddling in-person to replace unending back-and-forth messaging.

OCTOPUS

As a result, we are kicking off a major Inbasket redesign initiative. Although our inbasket settings were carefully considered and modified over the years since 2011 (our original Epic go live) with careful feedback from our physicians and informaticists, we still have opportunities:

Inbasket TECHNICAL changes:

• Eliminating “messages > 12 months old”
• Reducing the “FYI” and not-actionable messages
• Auto-deleting some categories of messages after some period of time
• Creating smartphrase responses to improve thoughtful responses to team mates and to patients
• Streamlining the ‘response buttons’

Inbasket WORKFLOW changes:

• Creating best-practice teamwork for “top of license” work
• Considering innovation tools to “auto-reply” to common questions
• Moving complex conversations away from portal messages to scheduled phone calls, virtual visits, in-person visits, urgent care as appropriate
• Considering billing for complex portal messages with patient consent

Just like with Physician Burnout and Wellness in general, there is plenty of work for everyone in Inbasket improvement: there are at least 8 arms to this octopus. Even if we can just “hack off” some of the arms (hmm, perhaps not the best metaphor for healthcare), we can certainly reshape the octopus into something more manageable (a starfish?).

STARFISH

CMIO’s take? Is your inbasket an octopus or starfish, or some other marine animal entirely? It is time for a wholesale re-imagining of our messaging and communications with patients and with each other. What are you and your teams doing in this area? Let me know.