In-Basket Reduction: A Multiyear Pragmatic Approach to Lessen the Work Burden of Primary Care Physicians

Abstract

Summary The in-basket of the primary care physician (PCP) has become unmanageable. A growing volume of messages from system notifications, communications from colleagues, and especially patient medical advice requests has resulted in several hours of such additional indirect care for physicians each day — and is a leading contributor to burnout. Atrius Health embraced this in-basket challenge in 2017, and the authors share their experience here. They determined that they could not effectively create efficiencies in practice for Atrius Health’s PCPs without tackling the in-basket. Atrius had used a team-based model of primary care for decades, but the in-basket processes did not reflect its care model of teamwork; in-basket messages defaulted to the PCP to manage and resolve. Feedback from PCPs, assessments of professional burnout, and measurement of PCP in-basket volume presented a clear need to address this issue. Atrius Health focused on reducing volume but considered performance in quality, safety, and patient experience in all work. The organization launched a multiyear initiative to reduce the burden of what should be a beneficial tool by applying the principles of eliminate, automate, delegate, and collaborate. By 2022, Atrius Health had reduced the in-basket volumes by category as follows: media manager (which refers to a folder in which scanned documents are filed), 98% reduction; carbon copy charts (which refers to notes from other physicians and contains a range of critical new diagnoses, prognoses, or treatment plans along with routine follow-up visits), 35% reduction; ED/hospital admissions/discharge/transfer messages, 100% reduction; prescription renewals, 50% reduction; laboratory results, 30% reduction; and patient medical advice requests, 40% reduction. Through a multipronged approach, the total daily in-basket volume for PCPs was reduced by approximately 25% from 100 messages in 2017 to 75 messages in 2022.