Abstract
Primary care physicians (PCPs) report multitasking during workdays while processing electronic inbox messages, but scant systematic information exists on attention switching and its correlates in the health care setting. To describe PCPs' frequency of attention switching associated with electronic inbox work, identify potentially modifiable factors associated with attention switching and inbox work duration, and compare the relative association of attention switching and other factors with inbox work duration. This cross-sectional study of the work of 1275 PCPs in an integrated group serving 4.5 million patients used electronic health record (EHR) access logs from March 1 to 31, 2018, to evaluate PCPs' frequency of attention switching. Statistical analysis was performed from October 15, 2018, to August 28, 2020. Attention switching was defined as switching between the electronic inbox, other EHR work, and non-EHR periods. Inbox work duration included minutes spent on electronic inbox message views and related EHR tasks. Multivariable models controlled for the exposures. The 1275 PCPs studied (721 women [56.5%]; mean [SD] age, 45.9 [8.5] years) had a mean (SD) of 9.0 (7.6) years of experience with the medical group and received a mean (SD) of 332.6 (148.3) (interquartile range, 252-418) new inbox messages weekly. On workdays, PCPs made a mean (SD) of 79.4 (21.8) attention switches associated with inbox work and did a mean (SD) 64.2 (18.7) minutes of inbox work over the course of 24 hours on workdays. In the model for attention switching, each additional patient secure message beyond the reference value was associated with 0.289 (95% CI, 0.217-0.362) additional switches, each additional results message was associated with 0.203 (95% CI, 0.127-0.278) additional switches, each additional request message was associated with 0.190 (95% CI, 0.124-0.257) additional switches, and each additional administrative message was associated with 0.262 (95% CI, 0.166-0.358) additional switches. Having a panel (a list of patients assigned to a primary care team) with more elderly patients (0.144 switches per percentage increase [95% CI, 0.009-0.278]) and higher inbox work duration (0.468 switches per additional minute of inbox work [95% CI, 0.411-0.524]) were also associated with higher attention switching involving the inbox. In the model for inbox work duration, each additional patient secure message beyond the reference value was associated with 0.151 (95% CI, 0.085-0.217) additional minutes, each additional results message was associated with 0.338 (95% CI, 0.272-0.404) additional minutes, each additional request message was associated with 0.101 (95% CI, 0.041-0.161) additional minutes, and each additional administrative message was associated with 0.179 (95% CI, 0.093-0.265) additional minutes. A higher percentage of the panel's patients initiating messages (0.386 minutes per percentage increase [95% CI, 0.026-0.745]) and attention switches (0.373 minutes per switch [95% CI, 0.328-0.419]) were also associated with higher inbox work duration. In addition, working at a medical center where all PCPs had high inbox work duration was independently associated with high or low inbox work duration. This study suggests that PCPs make frequent attention switches during workdays while processing electronic inbox messages. Message quantity was associated with both attention switching and inbox work duration. Physician and patient panel characteristics had less association with attention switching and inbox work duration. Assisting PCPs with message quantity might help modulate both attention switching and inbox work duration.
Highlights
Primary care physicians (PCPs) have identified the inbox within the electronic health record (EHR) as a source of work-related stress.[1,2,3,4] One possible reason is that it adds to the multiple demands that compete for PCPs’ attention during the workday
Having a panel with more elderly patients (0.144 switches per percentage increase [95% CI, 0.009-0.278]) and higher inbox work duration (0.468 switches per additional minute of inbox work [95% CI, 0.411-0.524]) were associated with higher attention switching involving the inbox
Meaning This study suggests that PCPs make frequent attention switches to and from the inbox while working, and interventions to assist them with message quantity could modulate both attention switching and inbox work duration
Summary
Primary care physicians (PCPs) have identified the inbox within the electronic health record (EHR) as a source of work-related stress.[1,2,3,4] One possible reason is that it adds to the multiple demands that compete for PCPs’ attention during the workday. Given that PCPs spend large portions of their time using EHRs,[5,6,7,8] electronic inbox work could be associated with many switches in attention when processing messages amid patient visits and other clinical responsibilities. Attention switching during medical work, whether due to external interruptions or internal volition, is of interest because it causes cognitive burden and may be associated with errors.[9,10,11,12,13] In studies outside medicine, email management has been associated with multitasking and stress.[14,15] Multitasking with email as measured by switching of computer screens is associated with inefficiency and feelings of diminished productivity.[16,17] to our knowledge, attention switching with the electronic inbox has not previously been studied in medicine
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