The Inbox Problem: Standardized Protocols for Primary Care Teams to Address Patient Messages

Primary care clinicians (PCPs) receive a high volume of patient messages through the electronic health record (EHR) inbox, which negatively impacts PCP well-being and retention. While recommendations to address the inbox problem have focused on leveraging care teams to address patient messages, there is limited evidence on how implementing standardized protocols for care teams impacts PCP workload.

To measure the impact on PCPs' workload of a quality improvement initiative using standardized protocols for primary care medical assistants and nurses to respond to patient medical advice requests (PMARs).

We performed a quasi-experimental pre-intervention/post-intervention study of this quality improvement initiative.

PCPs at 11 primary care clinics within a large academic health system.

A cost-neutral quality improvement initiative integrated standardized protocols embedded within the EHR to existing primary care clinical staff PMAR workflows.

The primary study outcome was the percentage of PMARs received by PCPs. We performed multivariable mixed-effect regression analysis to control for potential confounders and clustering by PCP.

The percentage of PMARs received by a PCP decreased from 61.6% in the pre-intervention period to 57.6% in the post-intervention period (p < 0.001). In a multivariable mixed-effect model, the odds that a PCP received a PMAR post-intervention was lower than pre-intervention period (OR 0.83, 95% CI 0.82-0.84), which corresponded to a 4.6% reduction in the adjusted means of the percentage of PMARs received by PCP between the pre- and post-intervention period.

Integrating standardized protocols into primary care clinical staff workflows was associated with a modest reduction in PCP workload. However, PCPs received more than half of all patient messages.