by Jill Clendening

It’s easy to become overwhelmed with electronic messages coming in from every corner. This has become especially problematic in health care, and Vanderbilt University Medical Center has just rolled out changes to streamline and better manage messaging between patients and their care providers.

“Increasingly, health care occurs asynchronously through the electronic medical record (EMR),” said Sara Horst, MD, MPH, associate vice chair for Digital Health Operations for the Department of Medicine. “While this may improve patient access to health care teams, several factors have increased the rate of patient use dramatically over the past decade. Medical practices and hospital systems have implemented EMRs that increase access through patient portals. The COVID pandemic also dramatically shifted health care into telecare. Studies have shown this has increased the number of messages exchanged in the EMR.”

Another factor in the increase in messages sent to health care teams through patient portals (at VUMC, these are delivered through My Health at Vanderbilt) is the implementation of the 21^st Century Cures Act, a federal law which requires that all health information, including test results, be immediately accessible to the patient.

“One study showed that when this was implemented at VUMC, the number of patient advice messages doubled within six hours of a test release,” Horst said. ^“Another study showed physicians with the highest quartile of messages experience six times higher levels of exhaustion. Asynchronous care is causing a significant and increasing burden on clinicians and nursing staff.  While there is no simple answer for this increasingly complex issue, VUMC wanted to improve workflows for both patients and care teams.”

Kelly Brown, MD, executive medical director of the Neuroscience Patient Care Center, led a team made up of physicians, nurses, information technology staff, managers and administrators that met for months to find ways to better manage the increasing tide of electronic messages. A survey was also sent to nurses about their priorities, and physician leaders brought input from their clinicians.

One resulting change that began in June was the implementation of eVisits, an initiative spearheaded by Horst. An eVisit is a patient-initiated, asynchronous conversation between a patient and their health care provider through a secure online portal. In this case, patients are using the Message function on the My Health at Vanderbilt portal to seek expert medical care that requires their clinician to spend longer than five minutes to respond.

“An eVisit is a service recognized by Medicare, Medicaid and all commercial health insurances,” Horst said. “Patients may be responsible for the same or lower copayment or coinsurance than they would have for a traditional office visit. It is great to have more options for continued care of established patients in addition to clinic and telehealth visits. Importantly, one primary care physician noted that this has helped her feel like she has more control over her message basket.”

Patients asking a medical question through My Health at Vanderbilt messaging will see information detailing the possibility of an eVisit in response to requests for complex medical advice, and that these types of requests could incur a coinsurance charge or a copay.  A website is available to answer patients’ questions about eVisits.

My Health at Vanderbilt messages requiring less than five minutes of a clinician’s time make up most of the electronic communications with Vanderbilt Health patients. These interactions, along with certain other exceptions, do not qualify as an eVisit and will not be charged. Examples include prescription renewals, appointment scheduling and other administrative actions.

“An eVisit is an opportunity to enhance patient access to asynchronous care while capturing clinician work and productivity and is increasingly being utilized in health care systems throughout the U.S.,” Horst said. “eVisits have already proven to be a valuable addition to how we provide personalized care. Since early June, VUMC physicians and advanced practice providers have completed more than 1,100 eVisits.

“In a survey conducted by our Telehealth team in late July, clinicians who had performed eVisits responded that they like the eVisit workflow, and they think patients appreciate this option for care. The VUMC Telehealth team will continue to work on ways to offer asynchronous care in the next year.”
Beyond eVisits, the work group arrived at many changes that would improve messaging in VUMC’s Epic EMR system, including the My Health at Vanderbilt patient portal.

“Our clinicians had been letting us know that they were inundated with a large number of messages from patients,” said Brown. “While we absolutely know the importance of patients being connected with their care teams, we felt we could bring this more into balance with minor adjustments to our messaging process. Early data has shown a 5% decrease in patient advice messages across VUMC and significant message decreases in other message basket types related to changes we’ve made in automated notifications.”

Changes include:

• Clinicians are no longer automatically notified if a patient hasn’t read a message in My Health at Vanderbilt within 48 hours. This accounted for as many as 60,000 notifications a month. In a two-week period after implementation, there was a 92.4% decrease in these types of messages.
• Updated wording for MHAV messages now reads that patients can expect a response within “2 business days.” Messages are not addressed on weekends or holidays.
• A time stamp or read receipt generated anytime anyone in a clinic “touched” a message has been eliminated. The time stamp did not necessarily mean their clinician had received a message, which patients didn’t always understand.
• The maximum character count for messages from patients to clinicians was reduced from 1,500 to 1,000 (a 33% reduction). This impacts more than 10,000 messages yearly.
• To improve workflow, chart review and clinical care, the length of time patients can reply to a message thread has been reduced from 60 days to 14 days. Patients can start a new message if needed.
• Staff messages were moved to a drop-down menu, requiring an extra step to enter a message. This is expected to help reduce noncompliant orders which could be related to staff messages not being automatically saved to a patient’s chart.
• Because patients don’t always answer calls from unrecognized numbers, an information banner has been added to My Health at Vanderbilt listing common VUMC phone numbers and encouraging patients to accept calls from these numbers.

Other changes:

• An update to the My Health at Vanderbilt Policy on Accessing Test Results that is in the approval process will clarify that supplementary messaging to patients regarding normal results for laboratory and other screening tests is not required as patients automatically receive these results. This will be at the discretion of the treating clinician.
• When patients call the Access Center or send a message, the information obtained may be incomplete. The Access Center is now using approved, standard forms when transcribing phone messages. These forms help to obtain adequate information to address the patient’s request without requiring additional calls or messages.

“We’ve made these changes to help our communications be more effective and productive for both clinicians and our patients,” Brown said. “We are continuing to share changes with patients that impact how they communicate with their care teams. Throughout the summer and into the fall, eStar education teams will be visiting clinicians and patient care center leaders to share information to help make their message basket use more efficient. We will also continue the eStar Efficiency Series presentations at Ambulatory Medical Director meetings.”