Team-Based Message Protocols Ease the EHR Inbox Burden on Primary Care Doctors

Every morning, before the first patient appointment begins, primary care physicians across the United States open their electronic health record inboxes and confront a wall of messages. Prescription refill requests, symptom questions, lab result anxieties, and administrative queries pile up in the digital in-basket, and the volume has grown relentlessly since patient portals became a routine part of medical care. A new study published in the Journal of General Internal Medicine offers a rare piece of good news in this landscape: a simple, cost-neutral intervention built on standardized protocols for medical assistants and nurses measurably reduced the share of patient messages landing on physicians’ desks. The reduction was real but modest, and the study’s most sobering finding may be what did not change: even after the intervention, physicians still received more than half of all patient messages.

The research, led by Matthew J. Mulligan and colleagues at the University of Utah’s Spencer Fox Eccles School of Medicine, addressed what has come to be known in health services circles as the inbox problem. Patient portal messaging exploded during the COVID-19 pandemic, when in-person visits were curtailed and patients turned to electronic communication for everything from routine questions to urgent concerns. Studies cited by the Utah team document the consequences: more time tethered to the EHR, longer workdays that extend into evenings and weekends, and measurable links between after-hours inbox work and clinician exhaustion. Prior analyses have associated high EHR time with degraded quality-of-care metrics, and surveys of physicians consistently rank in-basket management among the most demoralizing parts of modern practice.

The logic of the intervention was straightforward. When a patient sends a medical advice request through the portal, that message does not have to be answered by the physician alone. Medical assistants can handle many routine requests using standing protocols, such as confirming that a stable patient’s medication refill matches an existing care plan, or relaying normal lab results with prepared explanations. Nurses can triage symptom-related messages using established decision rules, escalating only those that genuinely require physician judgment. The University of Utah team embedded standardized protocols directly into the EHR, integrating them into the existing workflows of primary care clinical staff rather than creating parallel systems. Because the initiative used existing personnel and existing technology, it required no new funding streams, a design choice the investigators describe as cost-neutral.

To test whether this approach actually moved the needle, the researchers conducted a quasi-experimental pre-intervention and post-intervention study across eleven primary care clinics within a large academic health system. The primary outcome was the percentage of patient medical advice requests, abbreviated PMARs, that were ultimately received by a physician. This metric captures the fraction of message traffic that escaped the care team’s front line and reached the doctor’s inbox. The researchers used multivariable mixed-effect regression analysis, a statistical approach that controls for potential confounding factors and accounts for the clustering of messages within individual physicians, which is essential when some clinicians handle far higher volumes than others.

The results showed a statistically significant shift. Before the intervention, 61.6 percent of PMARs were received by a physician. After the standardized protocols were integrated into staff workflows, that figure fell to 57.6 percent, a difference with a p-value below 0.001, indicating that the change was very unlikely to be due to random variation. In the fully adjusted multivariable mixed-effect model, the odds that a physician received a given PMAR after the intervention were lower than before, with an odds ratio of 0.83 and a 95 percent confidence interval of 0.82 to 0.84. Translated into practical terms, the intervention corresponded to a 4.6 percent reduction in the adjusted mean percentage of patient messages reaching physicians.

Statisticians will note that an odds ratio of 0.83 describes a modest effect, and the authors are candid about this. A four-percentage-point drop in the share of messages reaching physicians will not, by itself, transform the working lives of primary care doctors drowning in portal traffic. Yet the study matters for several reasons. First, it demonstrates that a low-cost, workflow-embedded intervention can produce a measurable, system-wide change across a large network of clinics, not just a pilot ward or a single motivated practice. Second, it provides quantitative evidence for a strategy that national recommendations have long championed on theoretical grounds: leveraging the full care team rather than concentrating message work on the most expensive and most constrained resource in the clinic, the physician.

The broader context makes the modest effect size easier to interpret. The volume of electronic inbox messages has been rising for years, driven by portal adoption, patient expectations of rapid electronic communication, and algorithmically generated messages such as automated result notifications and care-gap reminders. Research published in Health Affairs in 2019 linked physicians’ well-being specifically to in-basket messages generated by algorithms, and studies of EHR use trends among academic primary care physicians from 2019 to 2023 found clinicians increasingly tethered to the record. Against this rising tide, even holding the line requires effort. A 4.6 percent relative reduction in physician-received messages represents swimming against a current that pushes in the opposite direction every year.

The Utah study also contributes to a growing literature on team-based inbox management. Previous work has explored using medical assistants to manage portal messages, nurse triage models for patient messages, dedicated in-basket managers sometimes dubbed inboxologists, and simple tools to reduce overall portal message volume. What distinguishes the new study is its systematic, multi-clinic evaluation with a clear primary outcome and rigorous adjustment for confounders. By embedding the protocols within the EHR itself, the team ensured that medical assistants and nurses encountered the decision support at the moment a message arrived, rather than relying on memory or separate reference documents. This design detail matters, because workflow integration is repeatedly identified as the difference between interventions that stick and those that fade after the initial enthusiasm.

Still, the headline finding cuts both ways. After the intervention, physicians received 57.6 percent of all patient medical advice requests, meaning the majority of electronic patient communication still demanded physician attention. The authors conclude that integrating standardized protocols into primary care staff workflows was associated with a modest reduction in physician workload, while emphasizing that PCPs continued to receive more than half of all patient messages. This residual burden has implications for clinician well-being and retention, both of which the study identifies as casualties of the inbox problem. Burnout research has repeatedly connected inbox volume and after-hours EHR time to exhaustion among primary care clinicians, and workforce analyses warn that the current design of primary care may be structurally unsustainable.

For health systems searching for actionable steps, the study offers a template. Standardized protocols can be written, embedded in the EHR, taught to medical assistants and nurses, and applied to the large category of routine patient messages that do not require a physician’s diagnostic reasoning. The intervention required only a small internal grant of ten thousand dollars from the University of Utah’s Division of General Internal Medicine, underscoring that the barrier is organizational will rather than capital. The remaining challenge, the data suggest, is larger: redesigning primary care so that the physician’s inbox contains only what genuinely requires a physician, while the rest of the care team handles the rest, safely and consistently. Until that redesign matures, the inbox problem will persist, but the Utah results show that even incremental, protocol-driven changes can shift the balance of work back toward the team.

Subject of Research: Impact of standardized care-team protocols on primary care physicians' electronic health record inbox workload

Article Title: The Inbox Problem: Standardized Protocols for Primary Care Teams to Address Patient Messages

Article References: Mulligan, M. J., Conroy, M. B., Codden, R. R., Wu, C., Flynn, M., Loucao, S., McCormack, E., & Johnson, S. A. (2026). The Inbox Problem: Standardized Protocols for Primary Care Teams to Address Patient Messages. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10643-9

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10643-9

Keywords: primary care, EHR inbox, patient portal messaging, team-based care, standardized protocols, medical assistants, nurse triage, physician burnout, quality improvement, electronic health records, clinician workload, patient messages