DDHA 8503 Week 4 Environmental Scan Example

Five Outside Pressures on a Primary Care Inbox, Ranked by How Far They Travel Inside: An Environmental Scan for a Fourteen-Clinic Medical Group

Student Name

Walden University

DDHA 8503: Strategic Management and Systems Thinking

Instructor Name

Month Day, Year

Five Outside Pressures on a Primary Care Inbox, Ranked by How Far They Travel Inside: An Environmental Scan for a Fourteen-Clinic Medical Group

Scope of the Scan

This scan looks outside Brightwater Medical Group, the composite fourteen-clinic primary care group whose patient messaging system was described and analyzed in earlier weeks. It identifies the external forces most likely to disturb that system over the next three years, places each at the point where it enters the organization and ranks them by how far and how fast their effects travel inward. The table comes first; the ranking and its reasoning follow.

The Forces at a Glance

Table 1

External Forces, Entry Points and First Disturbances

Each force is supported by a public source cited in the text below; entry points and timings for Brightwater are drawn from its own reports.

The Forces in Detail

Workforce supply. Primary care faces a continuing shortage of physicians, and national projections show demand exceeding supply through the mid-2030s (Association of American Medical Colleges, 2024). For Brightwater, the force enters through recruitment: positions take longer to fill, and departures are replaced slowly. It disturbs clinical hours offered, the variable that in the loop analysis connected burnout to visit availability.

Immediate release of results. Under federal information blocking rules that took effect in 2021, most test results must be made available to patients without the delay many organizations used to impose. Results now appear in the portal as soon as they are final, often before a clinician has seen them. Steitz et al. (2023), surveying patients at four health systems, found that most preferred immediate access even before clinician review, although patients receiving abnormal results more often reported increased worry. Worried patients write messages. The force enters through result notifications and disturbs the arrival of patient messages within days.

Rising portal use. Holmgren et al. (2022), studying clinicians' record use at a large health system, found that patient medical advice requests rose substantially after the start of the pandemic and did not return to earlier levels. Patients who learned to message their care team have kept doing so. The force enters through intake and disturbs arrivals over months.

Billing for message-based visits. Payers, including Medicare, recognize codes for online digital evaluation and management services, allowing some portal exchanges to be billed. Holmgren et al. (2023), examining one health system's decision to bill certain messages, found a small decline in message volume afterward, with only a small share of messages actually billed. The force enters through the billing office and the patient's statement, and it disturbs both the number of messages sent and patients' sense that the portal is a free channel to their clinician. For Brightwater, billing would also force a decision about exemptions, since a charge falls hardest on patients with high deductibles, who are not necessarily the patients sending the most messages.

Generative drafting tools. Record system vendors now offer tools that draft replies to patient messages for clinicians to edit. Garcia et al. (2024), in a pilot at an academic system, found that clinicians made use of only a minority of the drafts; their self-reported task load and work exhaustion fell, yet measured reply time did not change. The force enters at the clinician inbox and disturbs time per reply, possibly less than vendors claim.

Ranking by Depth of Propagation

The ranking orders forces by how deeply each one travels through the system described earlier, not by how often it is discussed.

First, workforce supply. It acts on clinical hours offered, which sit at the far side of the reinforcing loop from the inbox, and so it travels through visit availability into messages sent in place of visits and back into the backlog. It is slow, and it compounds the loop's own tendency to shrink clinical hours. It is the deepest force because it acts on the variable the loop already threatens.

Second, immediate release of results. It adds arrivals directly and also adds notifications to clinicians' inboxes. Because it raises the backlog within days, it pushes the loop toward the unfavorable direction quickly, though the loop's later links take months to respond.

Third, rising portal use. It raises arrivals steadily, which feeds the backlog. Its effect is broad but shallow per message, and it is partly a result of the loop itself, since patients who cannot get visits use the portal more.

Fourth, billing rules. These act on patient behavior at the point of sending and can reduce arrivals, but the evidence suggests a small effect, and they introduce a second disturbance, to trust and equity, that travels into patient relationships rather than into the inbox.

Fifth, drafting tools. They act only on time per reply and do not change arrivals, routing or clinical hours. Even if effective, they reduce one link's pressure without altering the loop's structure.

Forces Brightwater Is Least Equipped to Absorb

Two forces stand out. Workforce supply cannot be absorbed by changing messaging processes, and it intensifies the loop's most dangerous link. Immediate release cannot be avoided, since it is required by federal rules, and it adds arrivals faster than any staffing change can respond. Brightwater's strategy should therefore treat these two as conditions to design around, while treating billing and drafting tools as choices it can make or decline.

Two further forces were weighed and deliberately kept off the table: changes in state scope-of-practice rules for nurse practitioners and the consolidation of hospitals in Brightwater's market. Both matter to the group's broader strategy. Neither touches the messaging system within three years in a way that can be traced through its flows, so including them would have widened the scan without sharpening it. Both should be revisited when the scan is repeated next year.

References

Association of American Medical Colleges. (2024). The complexities of physician supply and demand: Projections from 2021 to 2036. https://www.aamc.org/data-reports/workforce/report/physician-workforce-projections

Garcia, P., Ma, S. P., Shah, S., Smith, M., Jeong, Y., Devon-Sand, A., Tai-Seale, M., Takazawa, K., Clutter, D., Vogt, K., Lugtu, C., Rojo, M., Lin, S., Shanafelt, T., Pfeffer, M. A., & Sharp, C. (2024). Artificial intelligence-generated draft replies to patient inbox messages. JAMA Network Open, 7(3), Article e243201. https://doi.org/10.1001/jamanetworkopen.2024.3201

Holmgren, A. J., Byron, M. E., Grouse, C. K., & Adler-Milstein, J. (2023). Association between billing patient portal messages as e-visits and patient messaging volume. JAMA, 329(4), 339-342. https://doi.org/10.1001/jama.2022.24710

Holmgren, A. J., Downing, N. L., Tang, M., Sharp, C., Longhurst, C., & Huckman, R. S. (2022). Assessing the impact of the COVID-19 pandemic on clinician ambulatory electronic health record use. Journal of the American Medical Informatics Association, 29(3), 453-460. https://doi.org/10.1093/jamia/ocab268

Steitz, B. D., Turer, R. W., Lin, C.-T., MacDonald, S., Salmi, L., Wright, A., Lehmann, C. U., Langford, K., McDonald, S. A., Reese, T. J., Sternberg, P., Chen, Q., Rosenbloom, S. T., & DesRoches, C. M. (2023). Perspectives of patients about immediate access to test results through an online patient portal. JAMA Network Open, 6(3), Article e233572. https://doi.org/10.1001/jamanetworkopen.2023.3572