EHR Inbox Uptick During COVID-19 Raises Clinician Burden Concerns

Medical and primary care physicians’ EHR inbox message volume increased over the course of the COVID-19 pandemic despite fewer patients receiving care, according to a study published in JAMA Network Open that raises clinician burden concerns.

The cross-sectional study examined deidentified EHR metadata from March 2018 to June 2021 in a large ambulatory practice network in New England. Researchers leveraged Epic Systems’ Signal tool to collect the data.

Between March 2020 and June 2021, the first 15 months of the COVID-19 pandemic, the average total messages per day increased from 45.0 to 46.0 messages per day for primary care physicians. Medical physicians, or physicians who are not surgeons and who do not practice primary care, also saw an increase in messages from 29.3 to 32.0 per day.  

Surgical physicians experienced the greatest uptick in EHR inbox messages during this time period, jumping from 16.6 to 23.3 messages per day.

Patient-originated messages also increased during the first 15 months of COVID-19. Specifically, patient medical advice requests (PMARs) increased from an average of 1.8 to 3.9 messages per day for primary care physicians; from 1.0 to 2.2 messages per day for medical physicians; and from 0.4 to 1.1 messages per day for surgical physicians.

Notably, the increase in EHR inbox messages came at a time when the number of patients seeking care from primary care and medical physicians decreased. Although the researchers said the influx of messages for surgical providers could be attributed to the clearance of backlog of elective surgeries delayed in 2020, the situation in primary and medical care is more elusive.

The researchers found that the increase in electronic messages from patients did not displace patient calls, as those also increased over the 15-month period.

Additionally, screen time spent in the EHR inbox went up from 21.7 to 25.1 minutes per day for primary care physicians; from 13.4 to 15.6 minutes per day for medical physicians; and from 7.6 to 11.1 minutes per day for surgical physicians.

The researchers acknowledged they may have underestimated how much time they spend in the EHR inbox because of how Signal defines and captures inbox activity. The clinician needs to actually be in the inbox screen for Signal to count inbox time, meaning the time clinicians spent answering phone calls or reviewing the medical record to answer questions weren’t counted for the study.

Nevertheless, the data indicate a serious upswing in the amount of time clinicians spend answering patient queries, raising alarms about clinician burden.

“Given the existing physician burnout crisis and the already known pandemic-related stressors and risks to the physician workforce, the additional inbox burden reported here warrants additional exploration to assess the nature of pandemic-related medical advice requests and the generalizability of these findings,” the study authors wrote.

“With COVID-19 potentially remaining a long-term endemic threat to public health, the priority to systematically address inbox burden before the pandemic through workflow redesign, team-based inbox management, and consideration of reimbursement for inbox-related work remains,” they continued.

This research adds to the growing body of literature surrounding EHR use and clinician burden.

In a recent study published in JMIR Publications, researchers from Kaiser Permanente equipped 42 outpatient clinicians from five separate medical facilities with wearable device heart rate sensors and the associated mobile apps. The devices tracked physiological stress throughout the workday based on heart rate variability.

Research revealed clinicians spent 3.5 hours within the EHR per day and 1.08 hours in the EHR inbox. On average, 37 percent of the 1.08 inbox hours accounted for patient portal messages, 31 percent accounted for laboratory results, 20 percent were clinical requests, and 13 percent accounted for administrative requests.

The device showed clinicians work within the inbox outside work hours, inside work hours, and in a post-work session tacked on at the end of their days.

Stress patterns showed the first hour of work, early afternoon, and in the evening as the top three time periods when clinician stress levels increased. Stress levels started to decrease from the morning until the lunch hour, and then it rose again at the beginning of the afternoon clinical shift.  

Clinicians who primarily conducted inbox work outside of regular work hours endured the most prolonged average stress duration of 80 out of 243 total work minutes.