Taming the In-Basket-How Two Simple Tools Reduced Portal Message Volume in an Academic Internal Medicine Clinic.

Abstract

Patient portal messaging has emerged as a critical tool in primary care, particularly during the COVID-19 pandemic, facilitating asynchronous communication between patients and providers. The surge in portal messages during the pandemic has exacerbated work overload and burnout among primary care providers. To enhance primary care clinic portal message workflow efficiency by identifying barriers through surveys and interviews, then implementing interventions to address challenges and streamline processes. We used a pre- and post-intervention with concurrent control design to evaluate this quality improvement project. The project was conducted at an Internal Medicine ambulatory clinic site within a large academic medical center in the Midwest. The quality improvement project involved primary care physicians, registered nurses, licensed practical nurses, medical assistants, and patient services associates managing patient portal messages in primary care clinics. Interviews and surveys assessed workflow practices, perceptions, and gaps. Interventions included developing "Best Practice Standards" and "Routing Guide" documents and restructuring staffing with dedicated time for message management. The co-primary outcomes were the volume of portal messages per physician clinical full-time equivalent (cFTE) and the proportion of message encounters with physician involvement. The secondary outcome was the proportion of messages sent to multiple recipients ("carbon copy" messages). The intervention site showed a 16% reduction in messages per physician cFTE monthly (RRR, 0.84; 95% CI, 0.75-0.94) and a 65% decrease in "carbon copy" messages (RR, 0.35; 95% CI, 0.31-0.39) compared to controls. Physician involvement in messages remained unchanged at the intervention site but increased 8% at control sites. Pre-intervention interviews identified workload, process, training, and stress barriers. Post-intervention, staff noted improvements from role clarification and dedicated message time. Targeted interventions can reduce portal message burden and improve workflow efficiency in primary care by implementing standardized protocols and clarifying roles.