Medicine is facing an information crisis. Beyond the increase in biomedical information, there is a growing demand for physician response to portal messaging (MyChart messages) and the review of data generated for laptops.
More recently, health professionals have seen an increase MyChart messages arriving through the Epic patient portal. According to Epic, the number of patient messages increased by 151 percent nationwide from the period that included the first 11 weeks of 2020 to the end of the year.
This change has been driven by health systems that actively promote the use of the portal. COVID has clearly driven remote attention. And in my experience the exchange of information from the Final rule of the Care Act has added a new dialog around the test results. The challenge has been that the workflows of healthcare professionals have not been adjusted to reflect this change in healthcare patterns.
In a pediatric gastroenterology practice, these messages can reach thousands of words in some cases. (As I have detailed in Looking for number two: a somewhat irreverent guide to poop, gas and other things coming out of your baby, young parents love to take pictures of their baby’s diapers. MyChart messaging has given new digital life to drum observers everywhere. But this is another post.)
UCSF’s Bob Wachter said this on Twitter recently:
We are seeing a huge increase in mailbox messages for doctors during Covid: it now appears to be the main driver of MD depletion. The fundamental problem: we activated 24/7/365 access for patients (who, of course, like it) without any operational or business model to manage it. It is crucial that we fix this.
As suggested by Dr. Wachter, MyChart messaging (for many systems) provides an example of what happens when we drop a tool in nature with no parameters for patients or professionals.
The consequence of this messaging mushroom is stress and ultimately exhaustion. And com recently suggested in the New England Journal of Medicine, One of the most important factors at play in the clinical setting is the apparent tension between availability and care.
Why MyChart messages create a challenge for hospital systems
So more contact and connection between doctors and patients seems like a good thing, right? Absolutely. But the problem is not contact and connection, but how we model and optimize the flow of information between physician and patient.
The zero-sum medical day
In many healthcare systems, the Epic feature is enabled and healthcare professionals are expected to respond. Then patients send as many messages as they want and make them as long as they want. The response burden then falls on the healthcare professional both ethically and legally.
The problem is that doctors work on what I call a zero-sum medical day. Essentially, there are only so many hours a day to manage new entries. And beyond a few hours, there is our bank of human attention and empathy. It’s the physics of the doctor’s bandwidth – you can’t add something without taking something out. Therefore, when we add a new type of access or task, we must consider what we will withdraw to allow this new service.
Without thinking about it, we end up with pajama time.
Maybe our healthcare model is flawed? In a value-based care delivery system, this can equate to more care (if any) through technological applications than through more expensive face-to-face encounters. While this can help zero-sum medical day at a level, compensation models do not necessarily solve the problem of human bandwidth.
Free range MyChart messages and the clash of expectations
When there is no consensus on how to use a tool, people will only do what they think. You can prove this by asking a lot of doctors and patients how they are supposed to use MyChart messages, you will get a wide variety of answers.
So integrated into the idea of “activating an epic function” is the challenge of expectations versus reality. Some of these epic features may create the expectation of a concierge-level service, a challenge at a time when hospitals are facing a global pandemic with crisis-level staff. We all want to offer our patients the best, but we need to consider all the things that compete for our care.
Inconsistency in the provision of care
Thus, as each provider sets up their practice around MyChart, each will do so in a slightly different way. Some will turn their practice into a virtual clinic with pajama “sessions” at night, while others will recognize the need for railings. And individual practice styles are fine. The problem comes with call and cross coverage. Patients will assume that there is a way to interact with the system. But this may not be applied consistently by other providers in the same group.
How do we fix it?
So how do we handle MyChart messages? A few ideas:
Stronger technological governance of MyChart messages
We want to call the MyChart mushroom an epic problem. But, like most problems like this, we are not dealing with a technological problem but a human problem. Ultimately, this is a failure to create parameters or orientation. For an industry that operates all our movements, the implementation of MyChart messaging has been strangely variable between and within systems.
The way we are charged for using (or not using) a particular technology must be a new priority of medical leadership. This includes clear message response time limits and standards.
Apply the correct connection to the problem …
We are developing a cabinet of communication tools to connect with patients, from synchronous (video visits and office meetings) to asynchronous (MyChart messages, recorded messages).
The problem with human communication is that it is nuanced. And the commitment to the disease is more complex. Healthcare professionals need to choose the right communication tool for the right problem.
This thread from a 2015 publication illustrates how the different needs of a child with ulcerative colitis require different ways to connect:
Take Luke, a school-age child with moderate ulcerative colitis complicated by sclerosing cholangitis. Consider the range of possible complaints and exchanges I might encounter with Luke’s mother:
I need the Asacol of Lukes again. Quite simple. A signal for action. No conversation needed. You don’t even need a doctor.
After decreasing Luke’s Assault, we noticed blood in the stool. Very simple too. He needs an exchange with a couple of questions and reassurance. It is easily performed asynchronously using secure text.
Luke woke up in the middle of the night with severe RUQ pain and fever. Potentially serious. Lots of questions to ask. You probably need a conversation, either by video or by phone. Too much generation and testing of immediate and time-sensitive hypotheses for text exchange.
We’re in Qatar, Luke’s bloody diarrhea is back. The local family doctor wants to use antibiotics and we need to know if we need to fly to Dubai. A safe conversation. The visual value for a scared family in a foreign land is difficult to quantify.
While technology providers of all kinds sell their tool as the best way to connect, it’s up to us to choose the right tool for the job.
… Then educate patients and doctors
Once we agree on how a tool will be used, patients need guidance. Patients need to know what tool to use to contact their healthcare provider and when. For example, “these scenarios are great examples of how to use MyChart.” And “these scenarios will require an IRL or a virtual visit with the doctor.” Helping patients understand how to manage a system’s communication closet will go a long way in improving the satisfaction of their encounters.
Although individual practice styles vary, patient expectations must be managed through consistent use of tools such as MyChart by practice groups. Ideally, this should be reflected in an entire institution, although variability by specialty is a reality.
My process with MyChart messages
My process is fairly straightforward – answering focused questions that can be answered safely and completely through a single text exchange. Long messages covering various concerns that require round-trip questions do not work as MyChart messages. If it looks like this, I go to the registry and suggest that the problem needs a call, a 15-minute TV, or an IRL meeting.
Healthcare professionals need to shape their tools
Finally, health care providers and patients need to play a more active role in shaping how we communicate.
There is an attitude in medicine that technology is deterministic: it is what it is and we simply take what they give us. Physicians in collaboration with patients should be part of the conversation that determines when and how we use (or don’t use) new technologies. Defining and refining communication tools is a problem of the health care provider and the patient, not an administrative or computer problem.
Andrew McAfee and Erik Brynjolfsson took this into account Machine, platform, crowd: taking advantage of our digital future:
Therefore, we should not ask ourselves “What will technology do to us?” but rather “What do we want to do with technology?” More than ever, what matters is thinking deeply about what we want. Having more power and more choices means our values are more important than ever.
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