Telehealth Use May Increase Physicians’ EHR Workload

Telehealth use during the COVID-19 pandemic was associated with an increase in the time physicians spent working in the EHR, though this work was largely related to documenting visits rather than messaging patients, new research shows.

The study published in JAMA Internal Medicine examined the correlation between telehealth use and time spent working in the EHR and patient messaging among ambulatory physicians before and after the onset of the COVID-19 pandemic.

Researchers studied the weekly EHR metadata of physicians at the University of California San Francisco (UCSF) Health. The physicians included in the study provided ambulatory care across 11 specialties, including cardiology, hematology, internal medicine, obstetrics and gynecology, and general surgery. The research team compared data from before the COVID-19 pandemic (August 2018 to September 2019) with data from the same period after its onset (August 2020 to September 2021).

The primary outcomes and measures were EHR time during and outside patient scheduled hours (PSHs), time spent documenting (normalized per eight PSHs), and electronic messages sent to and received from patients.

The study included 1,052 physicians with EHR metadata for 115 weeks. The mean weekly ambulatory patient volume increased slightly from 19.42 before the pandemic to 20.06 after, and telehealth use increased significantly from 3.1 percent to 49.3 percent.

The researchers found that from the pre-pandemic to the pandemic period, physician time spent working in the EHR during PSHs increased from 4.53 to 5.46 hours per eight PSHs. Similarly, physician time spent working in the EHR outside PSHs increased from 4.29 to 5.34 hours.

The time spent documenting during and outside PSHs increased from 6.35 hours before the pandemic to 8.18 hours after the pandemic began.

Additionally, the number of patient messages physicians received jumped from 16.76 pre-pandemic to 30.33 during the pandemic. The messages from physicians to patients increased between these periods from 13.82 to 29.83.

Physicians who provided care both through telehealth and in person in a week had 0.43 additional hours of EHR time per eight patient scheduled hours and 0.38 additional hours outside of scheduled hours compared with those providing care entirely in person.

The study findings have important implications for health system leaders, the researchers noted.

“Critically, the amount of time spent on EHR work among the physicians in this study underscores the importance of reducing burden: for every 8 PSHs, physicians were spending 5 or more hours outside PSHs working in the EHR. Health systems should consider the burden of EHR time for physicians who deliver care via telemedicine, when considering scheduling, number of patients under care (ie, panel size), and productivity expectations,” they wrote.

Further, they stated that future research should focus on whether team-based workflows that include non-physician staff could help reduce EHR time burden for physicians.

The study supports prior research showing that telehealth use leads to more after-hours work for providers, particularly EHR-based work.

The study published in 2022 included 2,129 physicians across various subspecialties related to internal medicine, ambulatory surgery, and general medicine. Work outside of work was the primary measure researchers used to assess work burden and how it fluctuates in accordance with telehealth use.

The researchers found that work outside of work was higher when physicians used telehealth. They made this observation at all stages of the pandemic and estimated that any decline in work outside of work resulted from a lower clinical load rather than telehealth assistance.

Work burden related to EHRs is also significantly associated with physician burnout. A study published in 2019 showed that clinical process design and the clinical structure, both of which are highly impacted by EHRs, contributed to approximately 40 percent of clinician stress.

The study, which analyzed survey responses from 282 clinicians on the impact of EHR use on stress and burnout, also shows that the time set aside for medical record-keeping doubled from 2009 to 2019.