COVID-19 Pandemic Triggered an Increase in Ambulatory Clinician EHR Use

Many ambulatory healthcare systems shifted towards virtual treatment in response to the COVID-19 pandemic, resulting in an increase in ambulatory clinician EHR use, according to a study published in the Journal of the American Medical Informatics Association.

To evaluate the change in clinician EHR use and workload, researchers used data from ambulatory care clinicians in 366 health systems using the Epic EHR system between December 2019 and December 2020.

Between December 29, 2019, and March 14, 2020, clinician EHR use ranged from 80.4 to 85.9 minutes per day, with an average of 84.3 minutes across weeks.

However, the findings showed that daily clinician EHR use dropped at the beginning of the pandemic and then recovered to higher than pre-pandemic levels by July 2020.

As the pandemic continued, more patients became aware of virtual treatment and tools such as secure messaging via the EHR and patient portals. The use of these communication tools has impacted the time required for those clinicians to manage the care of their patients through the EHR. 

EHR time per day declined to a low of 64.9 minutes in the week beginning March 29, 2020, representing a 23 percent decrease from pre-pandemic rates. During the week of June 28, 2020, EHR time increased to 85.7 minutes per day, a nearly 2 percent increase compared to the pre-pandemic mean.

Time spent actively working in the EHR after-hours showed similar results, with time per day reaching a low of 12.1 minutes during the week of April 5, 2020, and growing to 20.5 minutes during the week of June 28, 2020. 

Starting July 5, 2020, the total EHR time per day grew slightly higher than in the pre-COVID period, with a mean of 86.4 minutes across those weeks. EHR use after-hours experienced a minor increase of 2.06 percent compared to pre-pandemic rates and an average of 19.8 minutes during the same period.

Telemedicine demands more EHR time, specifically in EHR work outside of the traditional “visit” as clinicians rely more on EHR-based clinical review and receive more in-basket messages. 

At the beginning of the pandemic, time in clinical review per day decreased then increased significantly, with an average time of 17.17 minutes per day from December 29, 2019, to March 14, 2020.

Compared to pre-pandemic rates, time in clinical review increased 7 percent to 18.37 minutes per day from July 5, 2020, to December 2020.

“We found Clinical Review and In-Basket to be the main drivers of increased EHR work,” the researchers stated in the study. “For Clinical Review, it may be that telemedicine encounters led to an increased reliance on previous documentation and viewing of test results in the EHR or the increase in messages required clinicians to go back and review their documentation before responding to patients.”

In-basket messages where clinicians receive and manage messages from various sources increased dramatically during the pandemic. A study found that the percentage of clinicians reporting burnout increased from about 25 percent pre-pandemic to nearly one-third post-pandemic.

Compared to pre-pandemic levels, in-basket messages received per day increased by 4 percent during the week of July 5, 2020.

Patient messages were a significant driver of clinician workload, with clinicians receiving 157 percent more messages from patients per day than pre-pandemic averages. In addition, each patient message per day added 2.32 minutes of EHR use.

“Once patients became familiar with portals, they likely became more willing to message with clinicians,” researchers stated. “Given that the increase in patient messages was relatively stable through the end of 2020—even after telemedicine volume declined and in-person visits increased nationally. We suspect that the latter explanation is a more-prominent driver of increased messaging and that the higher message volume may persist in the post-COVID era.”

Furthermore, clinicians are rarely reimbursed for their time reviewing patient records and messaging patients. Working outside of scheduled clinic hours without reimbursement has been linked to clinician burnout, higher cost, and poor patient care.

EHR use was once cited as the top contributor to clinician burnout however, a study found that COVID-19 is now the main culprit as the pandemic has elevated all challenges related to clinical burnout.

Clinician burnout contributors, including after-hours workload, personal control over workload, the number of bureaucratic tasks, and chaotic workplace, have increased in severity during COVID-19.

Clinician turnover is also highly correlated with burnout. Providers who report any level of burnout are 68 percent less likely to report that they will stay at their organization. Since the start of COVID-19, the share of clinicians who have stated they will consider leaving their organization has increased from 20 percent to 25 percent.

In addition, clinician burnout can lead to post-traumatic stress disorder (PTSD), substance use, depression, and anxiety, a Physicians Foundations survey found.