Secure messaging increases oncologists’ workload, leads to high volume of unreimbursed care
Click Here to Manage Email Alerts
Access to personal medical information via secure messages in online patient portals has provided patients with an opportunity to become more involved in their care.
However, this effort — intended to improve clinician-patient communication — may come at the cost of increased provider workload.
Oncologists respond to an average of 19 secure patient-physician portal messages per day, according to study results.
Many of these messages could have been handled by another care team member and traditionally would have required a billable visit, researchers concluded.
Investigators estimated the unrealized value of medical care dispensed via secure messaging at more than $11 million.
“Based on my own experience, using secure messaging as a patient and managing my inbox as a physician, I suspected the ability of patients to message their doctor’s office directly ... had drastically reshaped how patients request and receive information from their medical team,” researcher Brandon Anderson, MD, internal medicine resident at Kaiser Permanente San Francisco Medical Center, said in an interview with Healio. “In turn, this further burdened the oncologists responsible for replying to them.”
Anderson spoke with Healio about the findings and the need to improve management of secure messaging.
Healio: What motivated you to conduct this study?
Anderson: When I began my residency, I spoke with my research adviser — Raymond Liu, MD — about many interesting topics within oncology needing further investigation. One of the issues we identified was rapidly growing post-pandemic burnout among oncologists. We suspected this was, at least in part, caused by an unprecedented uptick in nontraditional, unreimbursed telehealth work, including secure message management and care coordination.
I had just begun managing my own secure message inbox and knew the impact this research could have. I wanted to test whether my hypothesis regarding the inefficiency of the secure message system was accurate, and to alert hospital systems that a more efficient system is necessary for both patients and physicians to ensure quality of care.
Healio: How did you conduct the study?
Anderson: This population-based, retrospective cohort study examined the content of patient-initiated secure message threads exchanged through the patient portal over a 1-year period — June 1, 2021, to May 31, 2022 — at 21 Kaiser Permanente Northern California oncology practices. The cohort comprised over 41,000 patients who initiated more than 300,000 unique secure message threads to their oncologists. A randomized sample of 500 threads were selected for review of content and medical acuity and categorized by the designated appropriate level of service required (eg, oncologist, nurse, medical assistant, etc.) to provide a high-quality response. We compared a pricing model based on the percentages of threads that could be handled by alternate care team members with the estimated cost when all threads are managed by oncologists.
Healio: What did you find?
Anderson: The vast majority (73%) of messages did not require review by an oncologist and may have been more efficiently managed by another care team member. In approximately 24% of secure message threads, patients received medical care via message that traditionally would be provided through a revenue-generating in-person visit. Given that care provided through secure messaging is not billed in the Kaiser Permanente health care system, we projected that — when expanded to include the entire study cohort — the estimated unrealized value of medical care provided through secure messaging during the study exceeded $11 million.
This figure included $3.7 million in reduced out-of-pocket copayment costs to patients and $7.6 million in unbilled office visits to physicians. Assuming that secure message inbox management was compensated in Kaiser Permanente oncologists’ salaries, diverting threads that would have been more appropriately handled by other care team members would have saved Kaiser almost $1.3 million during the study period. However, as secure message inbox management is not directly compensated within the Kaiser Permanente system, this area requires additional research.
Healio: What do these findings suggest in terms of how these messages should be managed?
Anderson: The results overwhelmingly suggest changes in inbox management could improve patient and physician satisfaction and reduce health care expenditures. I believe the current secure message management system is founded on a well-meaning, patient-centered approach but — in its current form — unnecessarily increases the burden on oncologists without a proportionate benefit to patients. Further, the traditional fee-for-service approach does not account for reimbursed virtual care that patients have come to rely on in the post-pandemic era. These issues need to be addressed for secure messaging to be a sustainable method of delivery for patients, physicians and health care systems.
If — instead of being sent directly to oncologists — SMs were routed through an efficient triaging system, patients could receive the highest-quality responses to their inquiries by an appropriately trained staff member, with improved response rates and screening for emergencies. By redistributing secure message management, health care systems could significantly reduce medical expenditures and minimize oncologist burnout.
Healio: Is there anything else you feel is important to emphasize?
Anderson: Two additional findings of our study highlight the urgency for creating a new system to triage oncologists’ secure messaging.
First, in 2.4% of secure message threads reviewed, the medical severity of the patient’s initial message prompted the oncologist to recommend the patient seek evaluation in the ED. Although this percentage is relatively low ... the fact remains that some patients will reach out to their physician via secure message in times of urgent need. Improved screening of oncologists’ inboxes could introduce interventions in these cases, reduce response times and improve patient-centered care.
Second, although most replies to patients’ secure messages are sent during office hours, oncologists completed roughly 22% of their responses outside business hours. This is unsustainable. In a world with physician shortages, increased patient load and increasing use of secure messaging, this finding of work completed outside of work hours is likely a strong risk factor for oncologist burnout and identifies a tangible area for operational improvements.
Reference:
- Anderson B, et al. Abstract 1503. Presented at: ASCO Annual Meeting; June 2-6,2023. Chicago.
For more information:
Brandon Anderson, MD, can be reached at Kaiser Permanente San Francisco Medical Center, Internal Medicine, 4th Floor, 2238 Geary Blvd., San Francisco, CA 94115.
Collapse
Healio Interviews
Read more about
Click Here to Manage Email Alerts