S.O.S.: A Quality Initiative Aimed to Save Our Staff from the Increased Burden of Patient Portal Messaging

Purpose: Digital communication is rapidly evolving in community care practices. With 85% of our primary care paneled patients utilizing portal accounts, patient online portal messages to team pools and prescription refill requests increased 272% over a five-year period. Nursing and allied health staff support the practice with episodic patient care in addition to tasks such as prescription refills, pre-visit work, patient education, and reviewing and completing messages in message center. Messages were not addressed in a timely manner due to competing priorities. The additional non-visit care and clerical burden required a change to team workflows. an electronic medical assistant (EMA) role was developed to shift messages from nursing and provider in-baskets. The clinical background of an EMA adds value to message review and handling. Initial trial results showed that an EMA was able to manage 82% of patient medical advice requests and 47% of messages to patients.

Description: Results from the EMA trial helped to secure funding for a 12-month pilot to restyle two full-time medical assistants as EMAs. Goals were to reduce message volume downstream by capturing certain message types, increase efficiency and order by routing messages strategically, and have care team members work to their highest scope of practice. Each EMA was assigned to 11 providers. Two new in-baskets were created: one to address patient advice requests and one for prescription refills. In the 2-month training period, EMAs completed direct portal messages and provider requests to call results. A suite of smart phrases was created to provide language and tone consistency when communicating with patients. In addition, EMAs responded to incoming patient calls and assisted with prescription refills. Team member assignments were adjusted on high-volume message days. Data on in-basket total message volumes and number of refill messages for EMAs and providers was collected at pre-pilot, training, and post-implementation intervals.

Evaluation/outcome: Total in-basket message volumes increased for physicians and EMAs from pre-pilot levels to training and post-implementation intervals. However, the number of in-basket messages by user type indicated that physician patient advice messages decreased from 98% pre-pilot to 64% during implementation. Physician refill messages decreased from 100% pre-pilot to 69% during implementation. EMAs managed 28% of patient advice messages during training and maintained at 27% during implementation. EMA refill messages increased from 19% during training to 36% during implementation. EMAs had a sense of ownership, developed competence, and focused on message completion. The smaller feedback loop showed an increase in efficiencies while providing shorter message response times, which increased patient satisfaction. Smart phrases were well received by patients and the practice. The greatest impact to the practice will come from task shifting among remaining nursing and allied health staff. With the EMA managing patient messages, other team members can focus on clinical tasks nearer to the limit of their licensure such as pre-visit planning, wellness services, or procedures. This task shifting has potential for a greater impact to providers than patient message volume reduction alone.