Why academic physicians are still “tethered” to the EHR

Andis Robeznieks , Senior News Writer

While their volume of in-person patient visits has returned to near pre-pandemic levels, primary care physicians (PCPs) spend more time in the EHR than before patients were first encouraged to stay home to stem the spread of SARS-CoV-2.

The amount of time that academic primary care physicians spent “tethered” to the EHR was growing prior to the pandemic, and it has only gotten worse, according to a study published in Annals of Family Medicine. For the study, researchers tracked the workload of 141 academic medical center family medicine physicians, internists and general pediatricians from May 2019 to March 2023. 

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Researchers tracked the time these physicians—all with UW Health, the University of Wisconsin-Madison’s integrated health system—spent in different domains of the EHR per eight hours of scheduled clinic appointments.

Early in the pandemic, when the volume of in-person patient visits declined, primary care doctors used the gaps in their schedules to complete asynchronous patient needs in the EHR. Now, however, in-person visit volumes have essentially returned to previous levels, but PCPs are not seeing a corresponding decline in time spent in the EHR.

“We’re in a time of ‘both-and’ for PCPs,” said the study’s lead author, Brian Arndt, MD, a family physician at UW Health. “The simultaneous additional demands we are facing from the increased EHR workload is now stacked on top of our full patient care schedules.”

“It’s discouraging that our PCPs are spending more and more time in the EHR on days with scheduled appointments and on days without scheduled appointments,” Dr. Arndt added.

The study was supported by the AMA EHR Use Research Grant program, which has provided more than $2 million in funding for 26 studies to researchers nationwide since 2020. It built upon previous research done by Dr. Arndt and colleagues before the pandemic and subsequent studies done by others.

Messages related to orders rise most

During the study period, physicians saw an increase of 28.4 minutes in the time spent in the EHR per eight hours of scheduled clinic appointments—a 7.8% rise.

Growth areas included:

  • Orders: 23.1 minutes added, up 58.9%.
  • Inbox: 14 minutes added, up 24.4%.
  • Clinical review: 7.2 minutes added, up 13%.
  • Notes: 2.9 minutes added, up 2.3%.

Physicians spent 6.4 more in the EHR (8.2%) outside scheduled hours on days with appointments and 13.6 minutes more (19.9%) on days. without scheduled appointments.

Changes in inbox time included an additional 5.4 patient medical advice request messages (MyChart) per eight hours of scheduled appointments (55.5% over the study period) and 2.3 more prescription-refill requests (up 19.3%). There were also 2.8 fewer patient call messages (down 10.5%), and 0.3 fewer test-result messages (a drop of 2.7%).

The researchers noted that about 80% of UW Health patients are signed up for MyChart access.

“Although we observed a 10% decrease in the number of patient calls over the last four years, it was not nearly enough to offset the 56% increase in MyChart message volume we observed,” Dr. Arndt said.

Dr. Arndt and colleagues described the increased time spent in orders as “particularly concerning,” and speculated it could be, in part, a result of the increasingly complex patient messages.

“With large patient panels and very tight visit access, we’re working harder than ever with patients through MyChart to address their multiple issues without scheduling office visits,” said Dr. Arndt.

“It’s a several-times-per-week occurrence for me to interpret a 15-page continuous glucose monitor report uploaded by a patient in MyChart, respond to the patient with feedback on insulin adjustments, and order a follow-up A1c,” he added. “There’s no question it’s high value to both patient and payor but this high value, more complex work all keeps chiseling away from my time to exercise, sleep and spend time with my family.”

The study suggests solutions such as reducing inbox volumes through policy change, redesigning primary care workflows and teamwork, and resetting patient expectations.

“It is imperative health systems develop strategies to change the overall EHR workload trajectory to minimize PCPs’ occupational stress and mitigate unnecessary reductions in the effective physician workforce that result from the increased EHR burden,” Dr. Arndt said.