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Can the Inbox Ninjas Close Nagging Gaps in Primary Care?

Analysis  |  By Eric Wicklund  
   November 21, 2023

A new program at Bassett Healthcare monitors email inboxes and helps the health system react quickly to important patient emails.

With more and more healthcare being conducted online these days, health systems are struggling to get a handle on messaging between care teams and their patients.

Enter the Inbox Ninjas.

Launched in late 2022 by the Bassett Healthcare Network, the Ninjas are full-time advanced practice clinicians (APCs)–or staff with similar qualifications–hired by the health system to review email messages sent by patients to their care providers. The Ninjas separate the messages into different categories, giving high priority to messages that require action, such as answering an urgent medical question, scheduling an appointment, or filling a prescription.

The program addresses a vexing pain point for healthcare organizations, putting pressure on already stressed doctors to keep their inboxes up to date, even when they’re away. Missing those messages often leads to interrupted or delayed care, which affects care plans and clinical outcomes and boosts expenses.

Some health systems, including the Mayo Clinic, Cleveland Clinic, Vanderbilt Health, UCSF Health, Northwestern Medicine, BJC Healthcare, and even the Department of Veterans Affairs, are charging fees to answer emails, under the idea that a fee will cull out unnecessary messages and compensate care teams for their time.

Paul Uhrig, chief legal and digital health officer at New York-based Bassett and executive director of the Bassett Innovation Center, says leadership didn’t want to add that burden to their patients, many of whom live in rural areas and are concerned about the cost of healthcare.

“There’s a lot of messages coming into our providers now through the portal that need to be answered, and [those providers] were answering them during their pajama time,” he says, referencing the time spent by providers at home. “We wanted [a program] that takes the burden off them while not shifting that to their patients. We’re very conscious about not shifting cost to patients.”

Meeting a distinct need

Bassett launched the program to meet a very distinct problem. According to Halley Chiodo,  the health system’s telemedicine specialist, a large primary care provider in Cooperstown, New York, had closed down, leaving thousands of patients without a PCP. Bassett stepped into the void to help but needed a means of sifting through the inboxes of the departed PCPs, tagging urgent messages to prevent lapses in any care plans, and shifting those patients to new providers.

They had little to work with at first.

“We built this program from the ground up,” she said during a presentation at the Northeast Telehealth Resource Center’s (NETRC) annual meeting this fall in Nashua, New Hampshire. “We had no model to work with.”

Chiodo said management didn’t want to pull in current staff and add to their workflows, so they created a new position, one that is all-virtual and requires APC-level qualifications so that they can answer questions and fill prescriptions on their own (the health system currently requires a New York license and three years of clinical experience). The role seems especially suited to clinicians at the late stages of their career or in retirement, who might enjoy a job that they can do from home.

With approval from leadership to hire five FTEs, the program launched in late 2022. Uhrig said that while the initial intent was to focus on the inboxes of doctors who were no longer with the health system or those on vacation or out of office for a period of time, leadership realized the program could benefit any and all care providers.

It also became apparent very quickly that addressing every single email message would be too much, even for the Inbox Ninjas. Chiodo said the health system adjusted the protocols to enable the Ninjas to sort through all emails but answer only the priority messages.

“Nobody needs a clean inbox,” she said.

With that model, Chiodo said, the health system found that the Ninjas could also be put to use supporting Bassett’s telehealth programs, providing an extra layer of clinical backup.

Calculating the ROI

Both Chiodo and Uhrig say the Inbox Ninjas have been successful in cleaning up inboxes and addressing care gaps for patients, but whether that makes the program sustainable is uncertain. Chiodo—who noted Bassett is hiring more Ninjas soon—said the program is all-virtual, so the workforce is unique and requires a different management style. She also noted that other departments have asked about having their own Ninjas.

As for cost, the program can be adjusted to fit the needs of the health system. The higher level of clinical proficiency, the more that a Ninja can do with regard to fielding and addressing requests for medical services, which also means the money spent on staffing will increase.

Chiodo said the health system is working on a formula that would establish the number of billable clinical encounters needed to support one Ninja—while adding that ROI shouldn’t be linked solely to billable encounters. Uhrig, who noted the program did receive some outside funding to get off the ground, also noted the challenge of determining value.

“How do we turn some of these activities into billable activities?” he asked. At the same time, he added, there are benefits that aren’t billable, including improved patient satisfaction and engagement and a less-stressed corps of doctors who aren’t worrying about their inboxes so much. Eventually, he added, the health system might be able to link those timely responses to e-mails to specific improvements in clinical outcomes and reduced healthcare expenses, along with less staff stress, a better workplace, and improved staff retention.

Chiodo says there’s no shortage of qualified people who are interested in the job.

“After all,” she said. “Who wouldn’t want to be called a Ninja?”

“Who wouldn’t want to be called a Ninja?”

Eric Wicklund is the associate content manager and senior editor for Innovation, Technology, and Pharma for HealthLeaders.


Bassett Healthcare has hired several FTEs to review doctors’ email inboxes, prioritize those messages, and act on those requiring immediate attention.

The program was launched in 2022 to manage the inboxes of doctors who are out of office for an extended period of time, but now it is being expanded.

Executives say the program addresses requests for medical advice, prescription refills, and appointment scheduling, ensuring that care management isn’t delayed or interrupted.

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