Changes in Physician Electronic Health Record Use With the Expansion of Telemedicine
Authors: Holmgren A. Jay , Thombley Robert , Sinsky Christine A. , Adler-Milstein Julia 
Published: October 2023

Importance

Understanding the drivers of electronic health record (EHR) burden, including EHR time and patient messaging, may directly inform strategies to address physician burnout. Given the COVID-19−induced expansion of telemedicine—now used for a substantial proportion of ambulatory encounters—its association with EHR burden should be evaluated.

Objective

To measure the association of the telemedicine expansion with time spent working in the EHR and with patient messaging among ambulatory physicians before and after the onset of the COVID-19 pandemic.

Design, Setting, and Participants

This longitudinal cohort study analyzed weekly EHR metadata of ambulatory physicians at UCSF Health, a large academic medical center. The same EHR measures were compared for 1 year before the COVID-19 pandemic (August 2018-September 2019) with the same period 1 year after its onset (August 2020-September 2021). Multivariable regression models evaluating the association between level of telemedicine use and EHR use were then assessed after the onset of the pandemic. The sample included all physician-weeks with at least 1 scheduled half-day clinic in the 11 largest ambulatory specialties at UCSF Health. Data analyses were performed from March 1, 2022, through July 1, 2023.

Exposures

Physicians’ weekly modality mix of either entirely face-to-face visits, mixed modalities, or entirely telemedicine.

Main Outcomes and Measures

The EHR time during and outside of patient scheduled hours (PSHs), time spent documenting (normalized per 8 PSHs), and electronic messages sent to and received from patients.

Results

The study sample included 1052 physicians (437 [41.5%] men and 615 [58.5%] women) during 115 weeks, which provided 35 697 physician-week observations. Comparing the period before to the period after pandemic onset showed that physician time spent working in the EHR during PSHs increased from 4.53 to 5.46 hours per 8 PSH (difference, 0.93; 95% CI, 0.87-0.98; P &amp;lt; 0.001); outside of PSHs, increased from 4.29 to 5.34 hours (difference, 1.04; 95% CI, 0.95-1.14; P &amp;lt; 0.001); and time documenting during and outside of PSHs increased from 6.35 to 8.18 hours (difference, 1.83; 95% CI, 1.72-1.94; P &amp;lt; 0.001). Mean weekly messages received from patients increased from 16.76 to 30.33, and messages sent to patients increased from 13.82 to 29.83. In multivariable models, weeks with a mix of face-to-face and telemedicine (β, 0.43; 95% CI, 0.31-0.55; P &amp;lt; .001) visits or entirely telemedicine (β, 0.91; 95% CI, 0.74-1.09; P &amp;lt; .001) had more EHR time during PSHs than all face-to-face weeks, with similar results for EHR time outside of PSHs. There was no association between telemedicine use and messages received from patients, whereas mixed modalities (β, −0.90; 95% CI, −1.73 to −0.08; P = .03) and all telemedicine (β, −4.06; 95% CI, −5.19 to −2.93; P &amp;lt; .001) were associated with fewer messages sent to patients compared with entirely face-to-face weeks.

Conclusions and Relevance

The findings of this longitudinal cohort study suggest that telemedicine is associated with greater physician time spent working in the EHR, both during and outside of scheduled hours, mostly documenting visits and not messaging patients. Health systems may need to adjust productivity expectations for physicians and develop strategies to address EHR documentation burden for physicians.