MyChart Messages the Wild West of Patient Communication

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Medicine is facing a crisis of information. Beyond the increase of biomedical information are rising demands for physician response to portal messaging (MyChart messages) and review of wearable generated data. 

More recently health professionals have seen a rise in MyChart messages coming in through the Epic patient portal. According to Epic, the number of patient messages spiked 151 percent nationally from the period covering the first 11 weeks of 2020 through the end of the year. 

This change has been driven by health systems actively promoting portal use. COVID has clearly driven remote care. And in my experience the exchange of information from the Cures Act Final Rule has added new dialog around test results. The challenge has been that the workflows of health professionals have not been adjusted to reflect this change in care patterns.

In a pediatric gastroenterology practice these messages can run into thousands of words in some cases. (As I detailed in Looking Out for Number Two: A Slightly Irreverent Guide to Poo, Gas, and Other Things That Come Out of Your Baby, young parents love to take pictures of their baby’s diapers. MyChart messaging has given a new digital life to stoolgazers everywhere. But that’s another post.)

Bob Wachter from UCSF had this to say on Twitter recently:

We’re seeing huge uptick in in-box messages for MDs during Covid – now seems like biggest driver of MD burnout. The fundamental problem: we turned on 24/7/365 access for patients (who of course like it) with no operational or business model to handle it. Crucial that we fix this.

As Dr. Wachter suggests, MyChart messaging (for many systems) offers an example of what happens when we drop a tool into the wild without parameters for patients or professionals.

The fallout from this mushroom of messaging is stress and ultimately burnout. And as suggested recently in the New England Journal of Medicine, One of the most important factors at play in the clinical environment is the apparent tension between availability and attention.

Why MyChart messages create a challenge for hospital systems

So more contact and connection between doctors and patients seems like a good thing, right? Absolutely. But the problem isn’t contact and connection, but rather how we shape and optimize the flow of information between doctor and patient. 

The zero-sum medical day

In many healthcare systems the Epic feature is turned on and health professionals are expected to respond. Patients then send as many messages as they choose and they make them as long as they want. Then the burden of response then falls on the health professional both ethically and legally. 

The problem is that doctors work in what I call a zero-sum medical day. Essentially, there are only so many hours in the day to handle new inputs. And beyond just hours there’s our bank of human attention and empathy. It’s the physics of physician bandwidth: You can’t add something without taking something away. So when we add a new kind of access or task, we have to consider what w’ll take away to allow for this new service. 

Without thinking this through we wind up with pajama time.

Maybe it’s our faulty healthcare model? In a value-based system of care delivery this may equate to more care (where appropriate) happening through tech applications than through more costly in-person encounters. While this may help the zero-sum medical day on one level, compensation models don’t necessarily fix the problem of human bandwidth. 

Free-Range MyChart messages and the clash of expectations

When there’s no consensus of how a tool should be used folks will just do whatever they think. You can prove it by asking a bunch of doctors and patients how they’re supposed to use MyChart messages you’ll get a wild range of responses. 

So built into the idea of just ’turning on an Epic feature’ is the challenge of expectations versus reality. 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 staffing. We all want to offer our patients the best, but we have to consider all the stuff competing for our attention. 

Inconsistency in care delivery

So as every provider shapes her practice around MyChart, each will do it in a slightly different way. Some will convert their practice into a virtual clinic with late night pajama time ‘sessions’ while others will recognize the need for guardrails. And individual practice styles are fine. The problem comes with call and cross-coverage. Patients will assume there’s one way of interacting with the system. But this may not be consistently applied by other providers in the same group. 

How do we fix this?

So how do we get our hands around MyChart messages? A few ideas:

Stronger technology governance of MyChart messages

We want to call the MyChart mushroom an Epic problem. But like most issues like this we’re not dealing with a technology problem but a human problem. This is ultimately a failure to create parameters or guidance. For an industry that operationalizes our every move, the implementation of MyChart messaging has been oddly variable across and within systems. 

How we are charged to use (or not use) a certain technology has to be a new priority of medical leadership. This includes boundaries and clear standards of message response time. 

Apply the right connection to the problem…

We are evolving a wardrobe of communication tools for connecting with patients — from the synchronous (video visits and office encounters ) to the asynchronous (MyChart messages, recorded messages). 

The problem with human communication is that it’s nuanced. And engagement around disease is more complex. Health professionals need to pick the right communication tool for the right problem.

This thread from a 2015 post illustrates how varying needs of a child with ulcerative colitis call for different ways to connect:

Take Luke, a school-aged child with moderate ulcerative colitis complicated by sclerosing cholangitis. Consider the range of potential complaints and exchanges that I might encounter with Luke’s mom:

I need Lukes’ Asacol refilled. Pretty simple. A cue for an action. No conversation necessary. No doctor even necessary.

After decreasing Luke’s Asacol, we’ve noticed blood in the stool. Pretty simple as well. Needs some exchange with a couple of questions and reassurance. Easily conducted asynchronously by secure text.

Luke woke in the middle of the night with sharp RUQ pain and fever. Potentially serious. Lots of questions to ask. Probably needs a conversation, be it on video or telephone. Too much immediate, time-sensitive hypothesis generation and testing for text exchange.

We’re in Quatar, Luke’s bloody diarrhea has returned. The local family doctor wants to use antibiotics and we need to know whether we should fly to Dubai. A conversation for sure. The visual value for a frightened family in a foreign land is hard to quantify.

While tech vendors of all kinds are selling their tool as the ultimate way to connect, it’s on us to choose the right tool for the job. 

…then educate patients and doctors

Once we agree on how a tool will be used, patients need guidance. Patients need to know which tool to use to reach their health provider with and when. For example, ‘these scenarios are great examples of how to use MyChart.’ And ‘these scenarios will need an IRL or virtual visit with the doctor.’ Helping patients understand how to manage a system’s communication wardrobe will go a long way in improving the satisfaction of their encounters.

While individual practice styles vary, expectations from patients needs to be managed by the consistent use of tools like MyChart by practice groups. Ideally this would be reflected across an institution although variability by specialty is a reality. 

My process with MyChart messages

My process is pretty simple: focused questions that can be answered safely and completely by a single text exchange get answered. Long messages that cover multiple concerns requiring back-and-forth questioning don’t work as MyChart messages. If it looks that way I go on the record and suggest that the issue needs a call, a 15 minute televisit, or an IRL encounter.

Health professionals need to shape their tools

Finally, health care providers and patients need to play a more active role in shaping how we communicate.

There’s an attitude in medicine that technology is deterministic — it is what it is and we simply take what we’re given. Physicians in collaboration with patients need to be part of the conversation that shapes when and how we use (or don’t use) new technologies. Defining and refining communication tools is a health provider and patient issue, not an administrative or IT issue. 

Andrew McAfee and Erik Brynjolfsson had it right in Machine, Platform, Crowd – Harnessing Our Digital Future:

So we should ask not “What will technology do to us?” but rather “What do we want to do with technology?” More than ever before, what matters is thinking deeply about what we want. Having more power and more choices means that our values are more important than ever.

If you like this you might like our EHR Archives. It’s everything written here about electronic health records. Every post is carefully tagged to get you to related material. Happy reading. Every post has tags way down at the bottom that will guide you to related reading material.

The post MyChart Messages the Wild West of Patient Communication appeared first on 33 Charts.


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