The Contemporary "In-Basket": An Explosion of Unchecked Administrative Expectations

Patients are frequently encouraged to send messages to providers 'in-baskets" electronically in the medical record. In recent years, medicine has seen a dramatic expansion in the quantity of messages, requiring major administrative time, which is unchecked and overlooked by payors and hospital administrators. We sought to document the volume of the 'in-basket' of a hip and knee arthroplasty group at a single tertiary referral center.

The electronic "in-basket" was retrospectively queried from 2017 to 2024. Each message and reply from the total joint arthroplasty divisional pool was then counted. Subsequently, only patients who ultimately underwent total joint arthroplasty were evaluated. The quantity of hip and knee arthroplasty procedures was also documented during the same time. Data were evaluated using trend lines and Chi-square.

In-basket messages demonstrated an unparalleled expansion from 7,783 messages in 2017 (5,694 from surgical patients) to 105,348 messages in 2024 (71,216 from surgical patients). Although the volume of surgical cases nearly doubled during the same time period, the quantity of messages escalated by a factor of 13 (P < 0.01). Of the patients, 20% accounted for 59.2% of all messages.

To our knowledge, the exponential growth of in-basket messages in a contemporary academic arthroplasty group has not previously been documented in the literature. This demonstrates an insurmountable and uninhibited growth of a new clinician practice obligation that has no finite upper limit. Alternative models, including technology-based solutions and/or compensating dedicated time for these messages, will imminently be a necessity given the current trend.