Is the EHR Inbasket a Hyperobject? And what are you going to do about it?

Inbasket Hyperobject: hard to grasp, even harder to cut down in size.

https://www.wired.com/story/timothy-morton-hyperobjects-all-the-way-down/

This is a mind-blowing read. What is a hyper-object? It is a somewhat disturbing concept of something bigger than an object, something that transcends our understanding as a human. The concept’s inventor, Morton, defines it as: “phenomena too vast or fundamentally weird for humans to wrap their minds around.”

Okay. What?

Consider examples like “all the plastic in the world” or “climate change” or “a black hole” or “massive oil spills.”

Science fiction author Jeff VanderMeer has said “hyperobject” neatly describes the bizarre alien phenomenon he wrote about in Annihilation, his surreal novel turned 2018 movie.

Annihilation: Southern Reach Trilogy, Book 1 | Books, Novels, Audio books
from Jeff Vandermeer

OK, now that’s disturbing, as I read the book and felt chills during a summer evening. That guy can write. This is as close to a jump-scare that I’ve ever had, reading a book. Even had to put it down for awhile to calm down.  =shiver=

Now, I’m thinking: the Epic electronic health record’s INBASKET is a hyperobject.

EHR Inbasket as Hyperobject?

Now, we’re talking. Something that is weird, difficult for humans to grasp, and alas, vast. To the uninitiated, the Epic EHR inbasket is a message center where much of our internal communication takes place: incoming phone calls from patients can be sent to inbasket for nurses, docs, assistants to help manage the request; incoming patient portal messages come here; prescription renewals from pharmacies, from patients; consultation reports from specialists, hospital discharge summaries; notifications that “you did not finish writing this note for this patient visit”; test results from blood tests, radiology studies, biopsy reports; nurse-doctor communications; provider-provider communications. Lots of things.

And, for our busy clinicians, some inbaskets have dozens, hundreds, and sometimes THOUSANDS of unread messages that can be weeks, months, YEARS old. Yikes.

Hyperobject.

Solving the Rubik’s (hyper)cube?

First, improve teamwork, huddles

Ok, but that is a future post. Aside from the idea that we need to improve our internal teamwork and fundamentally redesign how we use our internal tools, there are some simple changes we can start with.

Time to cut our hyperobject down to size. We know that incoming inbasket messages from patients has tripled (see previous post). We know that our healthcare professionals are suffering from burnout (see previous post). We (I) have been guilty of delivering automated messages to our docs that we originally thought were helpful. Maybe it is time for a re-think.

Our plan to re-size our Hyperobject:

  • Pick a date (in December 2021), a one time PURGE of all messages 6 months or older in our Inbaskets. This is 7 million messages. Seriously. Rationale: If the provider hasn’t handled this by now, either the patient has called or messaged again (a more recent message), already come for a visit, or perhaps even left the practice to go elsewhere; there is NO VALUE in keeping these.
  • In December, begin a 90-day expiration clock on all new incoming messages. If you haven’t addressed a concern or responded or read a message by 3 months, it will disappear. Yes, there are theoretical risks of deleting reminders to complete a task or respond to a patient. But, here we are in mid November; is it still relevant that a patient called for advice in August, before school started? Also it is theoretically possible that a provider will stop someday and spend a weekend reading and replying to thousands of messages, but this is not likely at all. We are aware of some inbaskets with messages that number in the thousands. Yes, we are not proud of it. Our current setting where we NEVER delete old messages, I consider a personal failure of bad EHR design and configuration on my part. Behold: the man who ruined healthcare. :(. But, we’ll fix it now.
  • We are discontinuing the delivery of automatic CC (carbon-copy) messages from consulting specialists back to the referring provider and PCP (primary care provider). In 2011, CT Lin and his merry band thought we were doing everyone a favor by CRUSHING the BLACK HOLE (a DIFFERENT HYPEROBJECT!) of the University docs who never remembered to send a consultation letter back to the referring doc. “Hey, we sent you a patient for this clinical question, and WE NEVER HEARD BACK FROM YOU.” We created a technical solution to AUTOMATICALLY send a specialist’s clinic note back to the referring doc AND the primary care doc (if different). In the beginning, this was a great idea! However, this rule now sends several HUNDRED THOUSAND messages a year to our 6000 internal and innumerable community providers. I am personally burying my colleagues. Asking one of my full time internal medicine colleagues, he tells me “I receive about 100 to 150 auto-CC notes per week. Every couple of weeks I take a Saturday and read through 200-300 messages of which about 5 are useful to me. But I can’t NOT read them, what if I miss something?” What an excellent, OCD (obsessive compulsive) physician. But also the way to burn out on patient care. You work 40-60 hours a week and then spend evenings and weekends “catching up” on the blizzard of messages and tasks in the EHR. We need to do Today’s work Today. By the way, specialists can always manually send an important note back to the referring doc or PCP “hey, calling your attention to this” with a single click. And, our specialists ALREADY do this, so I often receive the automated note AND a manually sent note for specific concerns.

Thus, I feel pretty good about stopping the automation. How often do you read that sentence from a CMIO?

Clearly insane CMIO

To be clear, we have “internal” providers who use our Epic EHR and can look up the consultant specialist’s notes the next time they see the patient. These are the folks who will benefit. ON THE OTHER HAND, we have “external” providers in our communities who do NOT have access to our Epic EHR, they use a different EHR or perhaps are still using paper: We plan to continue to eFax or otherwise deliver these notes UNCHANGED. Thus, still addressing the community need for information and stopping the internal clogging of our own pipes.

Whew! That was a lot more long-winded than I intended, but this is a big deal, a big movement, that has already generated a lot of heat, a lot of concern about “why are you moving my cheese?” So far, in our internal provider discussions, we are hearing 90% support and 10% anxiety from our colleagues. We plan on moving forward and creating innovative solutions for those who do not see this as an improvement.

CMIO’s take? Hang on everybody. This Inbasket Hyperobject is getting resized. We have lots more plans for reducing the burden of inbasket messaging, this is just phase 1 of 4 major phases to come. Stay tuned!

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