Medicine is facing an information crisis. In addition to the increase in biomedical information, there are increasing demands on the response of doctors to portal messaging (MyChart messages) and the review of portable data.
Recently, healthcare professionals have seen an increase in MyChart messages received through the Epic patient portal. From the first 11 weeks of 2020 to year-end, the number of patient messages increased 151 percent nationwide, according to Epic.
This change has been driven by health systems that actively promote portal use. COVID has clearly advanced remote care. And in my experience, sharing information from the Cures Act Final Rule has added a new dialog around the test results. The challenge was that the health care professional’s workflows were not adapting to this shift in care patterns.
In a pediatric gastroenterological practice, these messages can be thousands of words long. (As I wrote in In Finding Number Two: A Slightly Disrespectful Guide to Poop, Gas, and Other Things That Come Out of Your Baby, new parents love to photograph their baby’s diapers. MyChart Messaging has a new digital life Stool watchers everywhere. But that’s another post.)
UCSF’s Bob Wachter recently said on Twitter:
We’re seeing a huge surge in inbox messages for MDs during Covid – now seems to be the biggest driver of MD burnout. The fundamental problem: We activated 24/7/365 access for patients (who of course like it) without an operating or business model. It is crucial that we fix this.
As Dr. Wachter suggests, MyChart messaging (for many systems) provides an example of what happens when we release a tool with no parameters to patients or professionals.
The consequences of this news mushroom are stress and ultimately burnout. And as recently suggested in the New England Journal of Medicine, one of the most important factors in the clinical setting is the apparent tension between availability and attention.
Why MyChart Messages Are Challenging Hospital Systems
So more contact and connection between doctors and patients seems like a good thing, doesn’t it? Absolutely. But the problem is not contact and connection, but how we design and optimize the flow of information between doctor and patient.
The zero-sum medicine day
Many healthcare systems have the Epic feature enabled and healthcare professionals are expected to respond. Patients then send as many messages as they want and keep them for as long as they want. Then responsibility for the response falls both ethically and legally on the healthcare professional.
The problem is, doctors are working on what I call a zero-sum medical day. Essentially, the day only has a limited number of hours to process new entries. And beyond hours there is our bank of human attention and empathy. It’s the physics of the range of doctors: you can’t add anything without taking something away. So when we add a new type of access or task we need to consider what we are taking away to make this new service possible.
Without thinking about it, we end up in pajama time.
Maybe it’s our flawed health model? In a value-based care system, this can mean that more care is provided (where appropriate) through technical applications than through more costly face-to-face encounters. While this can help medical zero-sum day on one level, compensation models don’t necessarily solve the human bandwidth problem.
Free Range MyChart News and the Clash of Expectations
If there is no consensus on how to use a tool, people will just do what they think. You can prove it by asking a number of doctors and patients how to use MyChart messages and you’ll get a variety of answers.
So in the idea of simply turning on an epic feature, the challenge between expectations and reality is integrated. Some of these epic features can create the expectation of concierge-level service – a challenge at a time when hospitals are facing a global pandemic with crisis-level staff. We all want to give our patients the best, but we have to consider all of the things that are competing for our attention.
Inconsistency in the care service
Since each provider designs their practice around MyChart, each will do this in a slightly different way. Some will convert their practice into a virtual clinic with nightly pajama sessions, while others recognize the need for guard rails. And individual exercise styles are fine. The problem comes with calling and cross reporting. Patients will assume that there is some way to interact with the system. However, this cannot be consistently applied by other providers in the same group.
How do we fix this?
So how do we get our hands on MyChart messages? A few ideas:
Stronger technology governance of MyChart messages
We want to call the MyChart mushroom an epic problem. But as with most issues like this, we are not dealing with a technology problem, we are dealing with a human problem. Ultimately, this is a failure to create parameters or instructions. For an industry that operationalizes every step we take, the implementation of MyChart messaging between and within systems has been strangely different.
How we are responsible for using (or not using) a particular technology must be a new priority for medical leadership. This includes limits and clear standards for message response times.
Apply the correct compound to the problem …
We develop a range 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 dealing with diseases is more complex. Healthcare professionals need to choose the right communication tool for the right problem.
This thread, taken from a 2015 post, illustrates how different needs of a child with ulcerative colitis call for different pathways to connect:
Take Luke, a school kid 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 Lukes’ Asacol refilled. Quite easy. A sign of an action. No need to talk. It doesn’t even need a doctor.
After lowering Luke’s Asacol, we noticed blood in the stool. Pretty easy too. Needs some sharing with a few questions and confirmation. Simply performed asynchronously through safe text.
Luke woke up in the middle of the night with sharp RUQ pain and a fever. Potentially serious. Lots of questions to ask. Probably needs a conversation, be it via video or phone. Too much immediate, time-critical generation and testing of hypotheses for text exchange.
We are in Qatar, Luke’s bloody diarrhea has returned. The local doctor wants to take antibiotics and we need to know whether we should fly to Dubai. Definitely a conversation. Visual worth for a frightened family in a foreign country is difficult to quantify.
While technology providers of all kinds sell their tool as the ultimate connection, it’s up to us to choose the right tool for the job.
… then educate patients and doctors
Once we have agreed on how to use a tool, patients need guidance. Patients need to know which tool they can use to contact their doctor and when. Example: “These scenarios are great examples of using MyChart.” And “these scenarios require an IRL or a virtual visit to the doctor.” Helping patients manage a system’s communications wardrobe will go a long way in enhancing the satisfaction of their encounters.
While the individual practice styles vary, patient expectations must be met through the consistent use of tools such as MyChart by practice groups. Ideally, this would be reflected in an institution, although the variability is a reality depending on the subject area.
My process with MyChart messages
My process is pretty simple: it answers specific questions that can be safely and completely answered through a single text exchange. Long messages that cover multiple concerns that require back-and-forth questioning will not work as MyChart messages. If it looks like that, I’ll go into the file and suggest the problem involves a phone call, a 15 minute television visit, or an IRL encounter.
Health professionals need to design their tools
Finally, healthcare providers and patients need to play a more active role in shaping our communications.
The mindset of medicine is that technology is deterministic – it is what it is and we just take what is given to us. Doctors need to be part of the conversation in collaboration with patients that determines when and how we use (or not use) new technology. Defining and refining communication tools is a matter for the healthcare provider and patient, not an administrative or IT issue.
Andrew McAfee and Erik Brynjolfsson got it right in Machine, Platform, Crowd – Harnessing Our Digital Future:
So we shouldn’t ask: “What will technology do to us?” But “What do we want to do with technology?” It is more important than ever to think carefully about what we want. With more power and more choices, our values are more important than ever.
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