In an age when instant gratification has become the norm — thanks in part to services now engrained in our daily lives like same-day delivery through Amazon Prime — many have come to expect easy access to people, products, and services at the click of a button. And connection to primary care providers through online patient portals is no exception.
Patient portals are ubiquitous in the U.S., with over 95% of hospitals reporting having one. Through these secure online websites, users can schedule an appointment, view lab results, and message their provider. It’s this last feature that has brought a “mixed bag” to the workday of a primary care physician, says Rob Doolan, MD, associate division head for clinical affairs in the University of Colorado Division of General Internal Medicine.
“You can enhance the physician-patient relationship with these interactions, but it comes at a cost,” Doolan says. “There's only so much time in the day for us to do our job. If that takes more hours than we have time for, it’s going to lead to unsatisfied physicians and patients.”
A few years ago, leaders in Doolan’s division and the CU Department of Medicine noticed that providers were reducing their patient-facing hours or leaving the clinic altogether. To determine the root cause, they convened a work group of physicians and advanced practice providers to explore the issue. The volume of patient messages quickly emerged as a top concern. While seemingly innocuous, the increase in messages and perceived need to reply promptly meant providers were stressed and overworked.
Since removing the ability for patients to contact their providers was not a realistic or even desired goal in today’s hyper-connected world, they developed a solution that allowed them to adjust, with measurable positive results.
“What we tried to do is recognize that this is our new reality,” Doolan says. “We needed to build some changes into our schedules to allow for this work and these interactions.”
Previously, the standard workweek for a primary care provider who sees patients full time was four days spent in the clinic and one day spent on administrative responsibilities. This left minimal time during clinic days to work on other tasks — called asynchronous work — which includes responding to patient messages, reviewing lab results, and connecting with care teams. While this was sustainable prior to the pandemic, it became unmanageable afterward as systems moved virtual and patient portal usage spiked, leading to an influx in messages.
Doolan and his team piloted five different change models to attempt to solve for the increase in asynchronous work. For three months, they tested blocks to a provider’s schedule, which looked different depending on the model. One had blocks that could not be scheduled into, another allowed for scheduling over blocks, and a couple versions looked at the physical space where the work was occurring, such as in an exam room or outside of the clinic. In addition to learning which models were operationally feasible, they also wanted to ensure there was a clear, positive impact on clinician satisfaction.
“We didn’t want to just jump in thinking that one model was going to be the best,” Doolan says.
After reviewing feedback from the initial phase, they moved forward with one scheduling method — 20- or 30-minute blocks every four hours that clinicians could schedule over if needed. The ability to schedule over blocks was a key factor to driving provider satisfaction, Doolan notes.
“Having the flexibility to adapt to unexpected situations and give some control back to the clinician was the real win here,” Doolan says. “Because let’s face it – days can go south for a variety of reasons. Letting it be the clinician’s choice to add a patient over the block was of significant value to them.”
The model was implemented as the scheduling standard a year ago and feedback has been overwhelmingly positive. Initial survey results from the pilot project show a reduction in clinician burnout, a decrease in the number of providers planning to leave or reduce their clinical work, and an increase in clinician and patient satisfaction scores.
“Initially we were worried about what patients were going to think about this,” Doolan says. “That was positive as well. They felt like the clinicians were deeper engaged, listened more, and were addressing their needs better.”
Anecdotal stories from providers bear this out. The blocks have allowed providers to see a message earlier in the day and get patients seen quicker, potentially preventing emergency room visits. At a more basic level, having the space to respond sooner meant that inbox volumes were decreasing because they were not receiving repeat messages for the same problem.
“If you can just lower the threshold of how much stress somebody's under, they can clearly relax and focus on the issue at hand,” Doolan says. “It goes better.”
Before the project could get off the ground, leaders in the division needed to convince hospital leadership of its value — knowing that there would be an expected loss in revenue from the reduction of clinical time.
“There was a lot of work that went into this,” Doolan says. “We had to address the real issues of visit volume, patient access, RVU production, and collections. We had plenty of meetings and hospital leadership was involved in each phase of the project. Even after that, they weren’t sure if they could agree. It just took a lot of conversations about what they needed and what we needed.”
In the end, they took a leap of faith, and it paid off. Clinical positions have stabilized and even grown since the project launched. While they projected a 12.5% loss in work RVUs — a measure used to determine the relative value of a procedure or service — and visit volumes, they only realized a 4% drop in both. This meant that clinicians were adding back patient visits into these blocks and increasing the complexity of the RVU billed.
“We're finding that our clinicians have more time to think about the patients they're actually seeing, and they don’t feel as rushed, so they can do a more comprehensive visit,” Doolan says.
They were also able to determine a right-sizing approach for how much time to block for asynchronous work. Twelve percent turned out to be the golden ratio — any more and RVU losses started to substantially increase.
In the future, Doolan hopes this idea can become a model at other organizations. Two publications are currently under review for this project that Doolan says will “really talk through all questions of why we did this, what we saw, why we made this our new model going forward, and where we're at. So I think this idea is going to expand.”
Photo at top: Rob Doolan, MD, reviews notes with team members. Photo by Justin LeVett photography.