Telemedicine is adding to doctors’ EHR burden

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While the increased availability of telemedicine in recent years may be convenient for patients, for doctors it has meant spending even more time in EHRs.

That conclusion emerges from a recent study of the association between telemedicine visits, the time doctors spend in the EHR, and patient messaging volume. And it may have important implications for how health systems and other large employers measure EHR burden.

Researchers from the University of California, San Francisco (UCSF) conducted a longitudinal cohort study of 1,052 UCSF ambulatory care physicians to compare time spent in the EHR before and after the onset of the COVID-19 pandemic, the event which brought telemedicine into widespread use.

They measured the time spent in EHRs both during and outside of patient scheduled hours (PSHs), EHR time spent on clinical documentation, and the number of messages sent to and received from patients via portals. Then they assessed how much of the change in each measure was associated with the level of telemedicine use

The data showed a significant, across-the-board increase in time spent working in the EHR following the start of the pandemic. During PSH it grew by 20% from 4.53 to 5.46 hours per 8 PSH, outside of PSH it increased by 24% from 4.29 to 5.34 hours, and documentation time during and outside of PSH increased by 29% from 6.35 to 8.18 hours. The results also revealed “a strong, positive association between proportion of encounters delivered via telemedicine and EHR time, both during and outside of PSHs.”

At the same time, the mean number of weekly messages received from patients grew by 81% from 16.76 to 30.33, and those sent to patients went from 13.82 to 29.83, an increase of 116%. The researchers found no association between patient messages received by doctors with telemedicine, but a strong negative association between telemedicine use and messages sent by doctors to patients. The latter resulted from fewer physician-initiated “cold” messages.

The authors suggest several possible explanations for the association between telemedicine and EHR time. One is that telemedicine allows doctors to compose their notes during the visit, which could appear in the study’s measure as more documentation time since the note is open.

A second possibility is that telemedicine use improves appointment adherence, leaving less of the time between appointments doctors previously used for documentation and requiring more post-PSH documentation time. It may be that telemedicine requires more pre-visit EHR review time since there is no physical examination of the patient. Finally, there may be less staff support in telemedicine visits for tasks such as recording the patient’s medical history, creating more EHR work for the physician.

The authors say their findings emphasize the importance of reducing EHR burden, noting that for every 8 PSHs, doctors were spending 5 or more hours outside PSHs working in the EHR. This means “health systems should consider the burden of EHR time for physicians who deliver care via telemedicine when considering scheduling, number of patients under care, and productivity expectations.

“If telemedicine remains more demanding of physician time,” they add, “policymakers should consider this evidence with the same weight as they give to studies on the quality of virtual care” when they make decisions about coverage and reimbursement.