Study Ties Pandemic Shift to Virtual Care to an Increase in EHR Use

The pandemic has pushed more care online, which in turn has also pushed clinicians back into the EHR, often after hours. That might be a problem.

A new study finds that the shift to virtual care during the pandemic has driven clinicians back to the EHR – with good and bad results.

As reported in the Journal of the American Medical Informatics Association, clinician time spent in the EHR had dropped prior to 2020, but it jumped right back up as COVID-19 took hold, especially after normal business hours. Researchers linked that increase to more time spent reviewing clinical notes and answering messages from colleagues and patients.

Researchers led by A. Jay Holmgren, of the University of California San Francisco’s Center for Clinical Informatics and Improvement Research said the increase was due in large part to the shift from in-person to virtual care, which pushed clinicians away from their patients and onto computers.

“The pandemic-driven shifts toward virtual treatment, and the corresponding change in patient expectations and awareness of communication tools such as secure messaging via the EHR, have substantially altered the nature of ambulatory care,” Holmgren and his colleagues wrote. “Further, as telehealth and the pandemic incentivized patients to become familiar with the use of online portals to access their health information and connect with clinicians, the time required for those clinicians to manage the care of their patients through the EHR increased.”

“The long-term shift to a mix of face-to-face and virtual care, as ambulatory patient volume returned in the second half of 2020, may have exacerbated these issues as clinicians delivered care across multiple modalities in a single day,” they added. “Given that many of these changes, such as increased patient familiarity with asynchronous messaging, may persist beyond the COVID-19 pandemic, it is critical to evaluate how they have impacted clinician work.”

The study adds a new wrinkle to the idea that the pandemic has helped thrust virtual care into the spotlight and given healthcare organizations more proof that they need to shift to a hybrid platform that mixes in-person care and digital health. It suggests that while telehealth and other digital health tools and channels may improve access to care, health system leaders need to understand how that shift affects clinician workloads, which could negatively impact care and increase stress.

The challenge will lie in mapping out hybrid care strategies that reduce that workload burden while still improving care outcomes, perhaps by shifting responsibilities to other members of the care team or integrating AI tools to automate some tasks. In simpler terms, they need to make the EHR easier to use – a task that has plagued the industry long before COVID-19 arrived.

“Although near-universal adoption of EHRs was an important enabler of the shift to telemedicine, increased reliance on EHRs may exacerbate existing issues of low job satisfaction and poor well-being amongst clinicians,” the study pointed out. “Many clinicians spend a significant amount of time working in the EHR, and clinicians in the United States already face a greater EHR burden than their international peers. Total time spent working in the EHR, ‘after-hours’ time working outside of scheduled clinic hours, and responding to In-Basket messages without protected time or reimbursement for messages have been associated with a variety of negative impacts, including burnout, which can translate into higher costs and lower-quality care.  Further, if the increased EHR burden is driven by activities such as messaging with patients, these new demands on clinician time may be concentrated on tasks that are outside of the bounds of the traditional ‘visit’ and are currently nonreimbursable for most clinicians.”

The researchers noted that policy makers should take these findings into account when developing coverage guidelines for virtual care. Current reimbursement guidelines don’t take into account the fact that patients are shifting to messaging platforms because they’re more convenient, thus adding to the clinician’s in-box. In addition, those guidelines have traditionally focused on documentation work, rather than the communicating with patients.

“This increase [in EHR use] was driven by time spent in Clinical Review and In-Basket messaging, with clinicians receiving 157% of their prepandemic baseline messages from patients,” the study concluded. “These patient messages represented a significant demand on clinician time, with each requiring an additional 2.3 [minutes] of daily EHR work on average. Policymakers and health system leaders looking to create sustainable workflows incorporating telemedicine in the post-pandemic period should be aware of these new demands on clinician time not only to avoid clinician burnout but also to accommodate rethinking the model of ambulatory medicine as patient expectations for care expand beyond the scope of the traditional face-to-face visit.”

Joining Holmgren in the study were N. Lance Downing and Christopher Sharp of Stanford University, Mitchell Tang of Harvard University, Robert S. Huckman of Harvard Business School and Christopher Longhurst of UC San Diego Health.