ASYNCHRONOUS CARE: THE RISING THREAT TO PRIMARY CARE SUSTAINABILITY

SGIM national meetings often have a prevailing buzzword that captures the salient presentations and hallway conversations that live in our community. Over the past 30 years, important buzzwords included nucleoside analogs, health maintenance organizations, and quality of care. The major new contender, and a rising threat to career sustainability in general internal medicine (GIM), is asynchronous care.

Synchronous care occurs when patient and provider convene in real time, either face to face or virtually. Asynchronous care is defined as “communication or information shared between providers, patients, and caregivers that occurs at different points in time.”¹ The term captures the triage and management of laboratory and imaging results, addressing patient-portal and phone messages, medication refill requests, facilitating interactions with multidisciplinary teams and home health providers, coordinating care with subspecialists, and completing the myriad panel management tasks. Some of these inputs require high-level clinical decision-making, but many do not. Some meet the important healthcare needs of our patients while others are of low value. These inputs come in addition to time-consuming preparatory data gathering before visits and often lengthy post-visit documentation. The buzz at the 2023 SGIM annual meeting was that this work is unreimbursed, invisible to those without panel management tasks and underappreciated by health systems. Functionally, asynchronous care creates cognitive overload, promotes moral injury through decay of work-life balance, and saps the joy of practicing GIM physicians.

A common sentiment among senior physicians is that processes existed prior to EHR implementation through which clinic staff streamlined physician work by filtering out non-clinical tasks. The EHR supplanted these processes by routing everything directly to the clinician. Secure messaging via patient portals introduced new inputs, and the volume of these messages exploded over the past 10 years, especially during the pandemic.²

The causal relationship between asynchronous care and physician burnout is firmly established as is the impact of burnout on care quality and patient satisfaction.³ The tsunami of asynchronous work is outpacing efforts to meet the demand. In addition to the discussion at the SGIM national meeting, we see increased provider burnout nationally and fewer graduating residents choosing GIM careers.⁴

As always, the SGIM national meeting brought substantial joy—reengaging with old friends and feeling stimulated by novel ideas. However, the gathering also brought memories of past crises that SGIM helped address: primary care for patients with HIV, stewardship of HMOs, and addressing gaps in quality and safety with research and leadership. GIM is disproportionally impacted by the burden of asynchronous care, but we are also well positioned to address this crisis. We excel at defining a problem, employing evidence-based interventions, and expanding that evidence-base through well-reasoned investigation. We are experts in collaboration and embrace interprofessional team-based care. These strengths are needed to address this complex issue.

In Denver, Colorado, several themes on asynchronous care emerged. First, primary care is a “public good,” and it is imperative for all stakeholders that primary care be a sustainable job. Second, we lack the analytic tools to target and track interventions designed to reduce the burden of asynchronous care. Investigators have found ingenious ways to use EHR activity logs to characterize asynchronous work, but local medical directors cannot easily measure the impact of interventions on their own clinics. Third, the interprofessional team—patient-aligned care teams (PACT)—with each member working at the top of their license, is the most powerful intervention currently available.⁵ We need to further study and refine our teams to maximize this resource. Fourth, the artificial intelligence (AI) revolution provides some optimism with the potential to aggregate and distill individual patient data to create problem representations, problem-based medication lists, or organize study results from voluminous medical records to support clinical decisions and streamline provider documentation.

SGIM should expand the dedicated space at future regional and national meetings for presentation of research and programmatic innovations addressing asynchronous care to drive change as it has for past healthcare dilemmas. Similarly, until asynchronous work is right-sized, SGIM needs to advocate for adequate time and meaningful credit from our hospital leaders. SGIM can be part of the solution by lobbying for work-credit for clinicians as their asynchronous workload skyrockets. Creating agreed-upon asynchronous care practice standards among our membership will not only improve our ability to effect change among healthcare organizations but also reinvigorate the sustainability of a primary care career.