EHR Inbox. Canadaian experience

Online messaging is a challenge in Canada perhaps even more than in the US

Onil Bhattacharyya MD.

Astounding conversion to virtual visit at onset of COVID-19 pandemic.

Physicians at one hospital message volume told the organization: WE ARE DONE. SHUT OFF THE MESSAGING. And messaging plummets.

Physicians viewed it as uncompensated and onerous work with lots of risk.

Is this a preview of what is coming in the U.S. if we don’t make a major change in our philosophy and workflow?!?

We must learn together how to do this better.

EHR Inbox seminar Liz Salmi

Liz Salmi tells us about the Patients Inbox. Her journey with a astrocytoma brain tumor and her medical sojourn. ‘An insane experience.’ And ‘I was anchored by the patient portal’

Liz Salmi on obtaining her records for the first time after being tested for brain cancer. ‘Seeing the notes was eye opening. I had no idea that this was the way my doctor saw me.’

From Liz on behalf of patients: Do the following (addressed to operational leaders and CMIOs)

1. Do get us on the portal

2. Do teach us about settings on the portal. because, look at this inbox burden on a patient with frequent radiation treatments.

3. Don’t assume what my preferences are. Make it easier.l to find and change settings. Immediate delivery? Once a day summary?

4. Do make sure to make Shared Access easy (what some called proxy access, which is confusingly named). It is really hard right now.

5 do offer guidance on test results.

Do tell patients about open notes. but don’t assume they are reading your notes.

Do add a thank you button.

How about a score on thumbs up for my doctor on my thank you.

Why aren’t all patients like Liz? There is a reason she is the @lizarmy.

EHR Inbox @UCSF Kaiser Permanente approach

3 premises. Inbox work is stress. Quantity drives workload. System leaders are needed to do this work.

Stomping grapes from the EHR audit log data to get wine. This is really hard work.

Measures stress with smartwatch use to measure heart rate variability during work day with EHR.

1. Inbox workload causes stress.

2. Volume of messages affect workload

3. System work needed to address this.

Using a smartwatch to measure stress.

Some astounding quotes of physician work life about inbox.

Components of stress: inbox work duration. Percent of work outside of work outs. And rate of window switching. !!

Arrghh. Task switching is HUGE. Physicans/APPs have no control over the volume and switching necessary to do this work.

A related analysis showed that variability between medical centers have big difference in inbox workload for involved physicians. So there are system effects here that are not technology based. (Same EHR different outcome).


Chris Sinsky speaking about the EHR transfer of work to physicians. And the impact of cognitive load on burnout. We are underperforming and under resourced in ambulatory care, nationwide.

Chris Sinsky MD: now refocusing the wellness and joy work at the AMA is focused on the inbox for 2023 and 2024.

What about the not -sexy ideas? is technology necessarily the solution for technology problems?

Also, although burnout manifests in physicians/APPs, it may originate in systems (how we work together in healthcare).

Consider that the EHR transferred work to the physician/APP. Liz Harry’s work on cognitive load demonstrates this.

Pajama time is, unfortunately a well known term now for how physicians work with the EHR into the evening on inbox work.

Physician don’t leave their job or their boss. They leave their inbox.

Interestingly, many docs are not quitting entirely, they are cutting back their hours and yet their inbox burden GOES UP AS a consequence.

And, it is worse for women physicians/APPs. And this is NOT because there are more women in the workforce. Hmm.

And here are some solutions written and summarized by the AMA. available at Steps Forward website with the AMA.

Some specific things you can do now. Including DC the CC.

The great news? There is so much opportunity for improvement in our systems.

This quote, from Catherine Lucey at UCSF as cited by Chris Sinsky, is everything.


Productivity paradox. Why are we not more efficient with fancier tools? But it should get better, right?

2 keys to unlocking the productivity paradox.

1. Improvements in technology.

2. Reimagining the work.

I love the way this man thinks. Thanks for making us look inside, as CMIO leader, and clinician, helping us image our future.

EHR inbox @UCSF

Bob Wachter MD citing Betsy Toll’s article on how EHRs have caused unanticipated effects on the patient physician relationship.

Queuing up the next thing: will speech recognition and GPT large language models change the way we use EHRs? Microsoft getting into the fray.

Bob now shouting out to OpenNotes, driving increased patient engagement and adoption of patient portals.

Overall across healthcare we are a victim of our own success. Patients like being better connected to their physician/APP/healthcare team.

Where do we go next? Because we cannot stay here where we are with the onbox burden.

EHR inbox conference at UCSF. Live posting

Liz Salmi and the author at UCSFs Inbox conference

Hearing from A Jay Holmgren about the explosion of inbox messaging.

And from Bob Wachter, chair of medicine at UCSF about the history of EHR deployments in the past decades.

About 100 attendees. We are looking forward to a robust conversation today.

Machiavelli, “The Spare” and Medical Informatics? A reflection

What does “The Prince”, Prince Harry’s new book, and Medical Informatics have in common?

It is a joy to have a son in college who is still interested in speaking to me, the old fuddy-duddy born in the Last Century. He is attending St. John’s College in Santa Fe, where they study the Great Books curriculum, or as his sister says, “Oh, so you read about ideas from old dead white men?”


It so happens that his class, which started with Aristotle, has worked their way up past Copernicus (my recent post on changing world-views), and now in the sophomore year, is now reading Machiavelli, perhaps my favorite of the classics, since it so much to say about the challenges of leadership.

Over dinner last week, my son and I discussed what I remembered from reading the Machiavelli’s “The Prince” in our Physician/APP Informatics Book Club (yes, we did), and the quotes that I use almost every week at work.

Why Change is Difficult to Lead

The reason that change in an organization is so difficult, is because at best, your proponents are lukewarm, and your detractors have ALL THE PASSION IN THE WORLD –CT’s recollection of quote

And it should be considered that nothing is more difficult to handle, more doubtful of success, nor more dangerous to manage, than to put oneself at the head of introducing new orders. For the introducer has all those who benefit from the old orders as enemies, and he has lukewarm defenders in all those who might benefit from the new orders… The lukewarmness comes from the incredulity of men, who do not truly believe in new things…  –Original text from Machiavelli

How to Manage Bad or Good News

If you have to manage change that people will like, be sure to do it a little at at time and take credit for every improvement, to sustain the atmosphere of good will. If you have to manage a change that people will NOT LIKE, do it all at once. In fact, hire someone to make that change, and, at the end, when they are very unpopular, BEHEAD THEM. Problem solved.
–CT’s recollection.

For injuries must be done all together, so that, being tasted less, they offend less; and benefits should be done little by little so that they may be tasted better.
–Original Text from Machiavelli

Application: we have a new committee, EMO (electronic medication optimization) where we are learning to remove low value medication warnings (eg: multiple stimulants in one med list – many patients have more than one Adderall pill strength needed for the right dose). Suppressing such alerts that are 90% overridden, is a benefit. Every time we reduce clicks, we Broadcast it. Take credit for every reduction, every improvement.

On the other hand, when there is something ‘bad’ we must change, we do it all at once. We have to wipe out physicians’ old radiology order preferences in order to install new radiology orders that incorporate secure chat buttons and more effective routing. DON’T get rid of them piecemeal (they will hate you every time you make a change) rip off the bandaid all at once and remove ALL the preference lists and start fresh instead. ONE painful change. But, the ONE event fades faster in memory than many smaller changes. (Yes, I know that CT Lin ruined healthcare, regardless of what he chooses).

Close readers of the blog will remember that our book club also read Leading Change and also Buy-In by John Kotter. Really practical advice on tackling the sticky issue of how to set up important changes for success.

How to Build Consensus

Back in 2009 when I invented APSO notes (a future post) I had difficulty convincing colleagues to switch to a different format of document. In brief, SOAP notes are how docs have written standard notes for 70 years. APSO puts the assessment and plan, the most important part, at the top for increased speed and readability.

However, I had failed. In our EHR (Allscripts Touchworks at that time) I made APSO a selectable option next to standard SOAP notes. Result? 16% adoption rate, even among my close friends and colleagues.

I had an opportunity in 2011 for a platform change (we were adopting Epic) and I had a committee meeting to see if I could get APSO as the default standard.

Machiavelli teaches us that, if you don’t already know how everyone will vote at an important meeting, you have not done your work.

In brief, I made 30 minute appointments with EVERY influential medical director in that 30-member meeting to discuss APSO, answer their questions and in some cases do some horse trading (this for that) to gain support. Took a couple weeks to do this ground work, for this crucial decision.

Result? I achieved consensus at the meeting. APSO notes were the default (and for a time the ONLY) format available in our new Epic EHR. Thanks, big M.


This brings us to Prince Harry. I recently listened to his book “Spare”. I had not followed the royal drama closely, and did not know that Spare was a disparaging name for himself, in contrast to “The Heir” Prince William, as in “there’s the Heir, and there is the Spare.” How awful. See last week’s blog post (below).

One presumes that the Royal education includes the reading of The Prince, for modern princes.

One also presumes that palace intrigue, public scrutiny, the fickleness of public opinion, all weigh heavily, magnified to searing intensity by social media and paparazzi (what would Machiavelli say about paparazzi?).

Similarly, those leading projects in large health systems must contend with large populations, difficulty communicating effectively, rumor, innuendo, opposing viewpoints, resistance to change (but perhaps, not paparazzi).

Medical Informatics

To bring these threads together, one sees ancient and modern examples of leadership, managing communication, remembering that smart humans lived many years ago and wrote down their ideas. It is up to us to learn history or be doomed to repeat it. Remembering my personal failures, my 16-year journey to Open Notes, my nearly-failed plan to implement APSO notes, and now our struggles to deploy, maintain, study and improve Open Results, these innovations have all been guided, in some way by Machiavelli.

CMIO’s take? Who is the historian in your leadership group? Who reads the literature, learns from the past, and gives your teams perspective? How do you ensure a diversity of opinion, of thought? How do you challenge and disrupt yourselves to avoid complacency? I worry about this all the time.

Prince Harry’s Spare (book review) and a CMIO’s reflection

Prince Harry’s autobiography is an enjoyable listen. For all the swirl about the Royal family, I almost never follow the Royal Family in the news. I was curious about Harry and Megan’s leaving the Royals and moving to Los Angeles, and so I was intrigued. And, I saw him on Late Night with Stephen Colbert. Here are the bare bones of salient facts:

  • William and Harry are sons of Princess Diana and Prince (now King) Charles
  • Diana died in a car crash after divorcing Charles, pursued by paparazzi
  • Paparazzi behavior, driven by newspaper and tabloid money in England, ultimately funded by the British public’s insatiable interest in the Royal family, is nearly unbelievable, and replete with examples of criminal behavior, as recounted by Harry and others.
  • Being in a Royal fishbowl can be intolerable and could and does prompt members to turn on each other.
  • Under the spotlight, everything is magnified: simple individual actions (or even inaction) can be interpreted as super popular or super villainous. Whatever sells papers.
  • Human behavior and relationships are difficult in any family. Under the public microscope it can be unimaginably difficult

The narrative on its own is an enjoyable listen. Harry narrates his own story from childhood growing up in the castle, losing his mom, being the Queen’s favorite, through a rebellious adolescence, into the military, training and flying missions as an Apache pilot, serving in Iraq and Afghanistan, meeting Megan, courting her, and ultimately leaving the Royal family.

I will not judge him for his actions or his writing. We all have limited skills in our relationships, coping skills for our pressures, joys in our pleasurable moments, grief in our catastrophes. It is too easy to ‘look over there’ and critique someone else’s life, not knowing the back story.

Too, it is easy to read an autobiography, adopt the authors views, and sense that everyone else must be evil.

CMIO’s take? I have lots of conflicting emotions about this, and find lots of parallels working with and leading humans in a large organization. I notice that my reactions are a litany of emotions, and less an intellectual response. And yet…

  • Most everything said is a viewpoint. Take them with a grain of salt
  • It is too easy to judge. Turn the judgement back on yourself when you feel it. Do you really know, for example, what it is like to live in a castle pursued by drone-wielding and motorbike-riding paparazzi, and loved ones suicidal from the aggressive hounding, having lost your mother, whose death was directly related to being pursued by those same individuals? What traumas are we each seeking to leave behind, ourselves?
  • The range of human experience is astounding. Sometimes just appreciating that is enough
  • What lessons on egotism can I learn from this? What lessons on brotherliness? On parenting? On collegiality? On grit? On grief? On anxiety? On empathy? What blind spots does this bring up?
  • Prince Harry is the Spare, the denigrating term for the second son who is not ‘The Heir’. This microcosm of an extreme situation, even if written as a grievance, an explanation, can tell us so much about ourselves, about myself.
  • For this, Prince Harry, Duke of Sussex, I am grateful.

Speech Recognition In the Exam Room with patients: could this work for you?

Speech recognition has been used in medical practice for years. Some physicians/APP’s use this in the exam room. What do patients think of this? We studied this, and published on this topic, come along for the ride …

Dr. Jeffrey Sippel, pulmologist at the University of Colorado School of Medicine, Anschutz Medical Campus

At long last! Dr. Jeffrey Sippel, Dr. Tim Podhajsky and I have been thinking about this for a few years. Speech recognition engines have been improving steadily for years now, and I (CT) have been using it for over almost 2 decades.

Leaving aside the improvements with DAX express (look it up; will be interesting very soon, ambient listening of a 2 person medical interview with AI-generated progress notes), what could Speech Recognition in the exam room do with the physician-patient relationship?

Funding for studies

Here is both encouragement for my colleagues and admiration for those who have figured out how to get external funding for research or projects.

We do many studies like one this WITH NO FUNDING. Just doing our usual job, having a good idea and then applying a generous amount of elbow grease, weekend and evening hours spent thinking, designing, writing, submitting an “exempt IRB application” for a Quality Improvement Project. Then, once granted, figuring out how to beg, borrow, steal the tools, experts and resources needed to do the work, set up the right patient or physician/APP population, do a paper survey, collate, meet regularly to think and write up the results, then submit for publication.

The secret to success is: choosing simple questions to ask, projects that don’t require new expensive equipment, and then REGULAR WEEKLY OR MONTHLY MEETINGS to hold each other accountable to make slow steady progress on your collaboration. This is the roadmap for our success in this project (and many others).

I want to thank Holly Hockemeier for her generosity in donating several dozen Dragon Speech Microphones to our project to get it off the ground (Hi, Holly! Thanks to you and the Nuance team!).

What did we find in the study?

Short answer: in the report above with 65 patients across 3 medical offices, patients highly preferred having a physician use speech recognition (microphone in the exam room) to generate “assessment and plan” recommendations for the patient, that they would take home with them.

This is the first report of using Speech Recognition in this way in the exam room. Do you use Speech Recognition in your practice? Then, WITHOUT the FANCY DAX (Dragon Ambient eXperience) “tools of the future”, you can do what we did TODAY.

Trouble with the History of Present Illness

Over the years, I tried quite a few techniques with speech recognition. First, I tried using speech recognition throughout an entire patient visit. This is how the intro conversation went:

Me: “Hi Sarah, good to see you again. Since you’re a technology nerd like me, while we are talking today I’m going to try using my speech microphone during the visit. If this works, I can print you a copy of my note that I write about you today. Would that be okay?”

Sarah: “Sure! Sounds interesting”

Sarah would tell me her medical symptoms over the past few months since our last visit. This time, I would then summarize her symptoms while looking at the computer screen. I ran into trouble right away:

  • The speech engine was slow (2011) and was 2-3 seconds returning text to the screen. So while I was dictating, it was typing about 1/2 sentence behind. I found I could NOT look at the words appearing on the screen and also compose the rest of the sentence at the same time.
  • Summarizing the patient’s history right after she spoke it was increasing the time it took to record a history. Normally I would make cryptic notes on paper (or type into the computer) while listening. Now, I would have to tell the patient “Stop Talking. It is my turn to tell the computer something.”
  • Worse, if I was typing on the computer (yes I do touch-type), I was looking at the screen instead of the patient. Significant disconnect for eye-contact during the medical interview.
  • Even worse, for less tech-savvy patients, I would say something like “Mrs. Jones states her sister has diabetes” and she would interject “No, not my sister, my cousin.” I would then have to sternly remind the patient: “When I am talking to the computer YOU HAVE TO BE QUIET NOW.”

And then Dragon would type on the screen “Mrs. Jones states her sister has diabetes no not my sister my cousin.”

Conclusion: not great for HPI.

Physical Exam and Speech

What would happen as I tried to do the physical exam with speech recognition in the exam room? I moved the patient to the exam table, do my exam. Not having a fancy bluetooth microphone, I could not speak as I was doing my exam. Then I’d have to return to the computer to document my findings. Not terrible, but not great, and took more time. Also, speech tools were generally slower than using a Macro to select mostly normal findings in the EHR.

Conclusion: not great for physical exam.

What about the Assessment and Plan?

Well, then, is Speech Recognition good for ANYTHING in the exam room? It turns out, YES. By the time we get to A/P, I’m usually doing a monologue for the majority of this time, for example “Here’s what I heard, here’s what I’m thinking, here’s what I propose we do, what do you think?”

Assessment and Plan in the exam room IS A SLAM DUNK

With some revision over the years, here’s what I say now (with ALL CAPS indicating the Speech Recognition COMMANDS):

Me: “Mrs. Jones, I’m going to talk to the computer now, while I speak to you about my thoughts. It is going to sound a little funny, but follow with me and and I’m going to ask if it makes sense to you. If you agree, I’ll print a copy for you to take home.”

Mrs. Jones: “Okay.”

“Assessment and Recommendations – COLON – NEW LINE
NUMBER ONE PERIOD High blood pressure PERIOD Your blood pressure looks great today PERIOD It is 122/70 today and the losartan is not causing any side effects PERIOD Please continue taking one every day and check your blood pressure reading once a week and write it down for us to review in 3 months PERIOD”

“MICROPHONE OFF” (to patient) Does that make sense? Any questions?

Mrs. Jones: “And losartan doesn’t cause cough, like the lisinopril before, so that’s good, right?”

“MICROPHONE ON I’m glad that the losartan is not causing cough PERIOD This is why we switched to this medicine, which seems to be working well PERIOD”

Wow factor

This way, I give the advice ONCE.
The computer hears and transcribes immediately.
I maintain eye contact with the patient while speaking.
The patient can correct me as we go.
The patient is hearing reflective listening and hearing the plan out loud.
I can print and hand the patient the summary immediately.
The patient is astounded at the on-screen typing he/she can watch live.
Often, patients will bring their last summary and indicate what they have accomplished since last visit. Win-win.

Advanced skill: Mini SOAP notes

In fact, now I have adjusted to include a brief HPI and exam right into the A/P, making tiny SOAP notes for each separate problem like this:

“MICROPHONE ON Assessment and Recommendations COLON NEW LINE NUMBER ONE High blood pressure PERIOD Patient states she started on losartan 1 month ago and has had no side effects PERIOD Her potassium and creatinine test was normal yesterday and her blood pressure today is 122/70 PERIOD NEW LINE ALL CAPS Plan COLON NEW LINE Please continue losartan PERIOD I am glad it has not caused cough and that the blood pressure looks great PERIOD Keep checking your BP at home once a week and lets see you again in 3 months PERIOD Let me know via the patient portal if you have any questions or concerns. MICROPHONE OFF.

Grace notes

  • Having a mini SOAP note for each diagnosis works great, like a tiny capsule summary for each separate condition.
  • If you are using speech recognition DO NOT LOOK AT THE SCREEN. Cognitive interference will ruin your sentence composition
  • If you don’t look at the screen, LOOK AT THE PATIENT. Better eye contact!
  • If you are looking at the patient MIGHT AS WELL DICTATE IN THE SECOND PERSON. Not: “The patient will …” but “You and I have agreed to …” In the beginning, colleagues objected “This seems unprofessional to talk about ‘you’ and not ‘the patient’.” to which my argument is “Who is the most important customer for your progress note?”
  • Yes, proofread your speech, but EVEN IF YOU DON’T the patient heard you in-person and can still understand what was said. In 10 years of speech rec in the exam room I have only had ONE PATIENT bring back a print out and ask for a correction.

CMIO’s take? Come join us! Try Speech Recognition in the Exam Room. There is NO DOWN SIDE. Only time savings for physicians/APP’s, better reflective listening for patients and more timely documentation.

“summarize this article in less than 280 characters”


Patients have a very positive perception of speech recognition use in the exam room. A survey of 65 patients found that 86% agreed or strongly agreed that their provider addressed their concerns better when using speech recognition, and 73% agreed or strongly agreed that they understood their provider's advice better. Patients were also more likely to recommend a provider who used speech recognition.

This study suggests that speech recognition can be a valuable tool for improving patient care. It can help clinicians to take better notes, which can lead to more accurate diagnoses and treatment plans. Additionally, it can help patients to feel more involved in their care, as they can see the notes being taken and ask questions about them.
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