Clinic Days with Telemedicine, In-Person Visits Increases EHR Work for PCPs

A new cross-sectional study found clinic days with telemedicine and in-person visits led primary care physicians (PCPs) to experience 5 to 6% more electronic health record (EHR)-based work.¹

However, on more than 300 PCPs and nearly 68,000 PCP-day observations, the work did not continue into next-day documentation, meaning the physicians absorbed added time into their workload during mixed-modality days.

“Greater EHR time may be due to increased multitasking during telemedicine visits, as PCPs simultaneously engage with patients and the EHR during telemedicine visits in ways that are not possible in person,” wrote the investigative team led by Nate C. Apathy, PhD, National Center for Human Factors in Healthcare, MedStar Health Research Institute.

Offering the potential to provide low-acuity medical services, at a lower cost, telemedicine use increased significantly in the face of events like the COVID-19 pandemic.² However, telemedicine can levy new costs on clinicians, shift care delivery workflows, and involve complexity similar to in-person visits, without an added clinical support team.

In particular, recent evidence has linked greater weekly telemedicine visits with increased EHR time, including after-hours time.³ For this analysis, Apathy and colleagues sought to address whether day-to-day changes in telemedicine use create a similar association with EHR time.¹

The cross-sectional analysis combined visit modality data with EHR active use data on time spent by PCPs from December 2021 to June 2023 at the investigators’ site. Investigators calculated the PCPs’ daily telemedicine share as the percentage of the day’s telemedicine visits and classified this variable into five levels.

Five measures of active EHR time for each PCP day included the total EHR time, documentation time, medical record review time, order time, and next-day documentation time, but only for PCP days with a consecutive qualifying PCP day.

A total of 316 PCPs were observed across 67,894 PCP-day observations distributed across the 5 daily telemedicine share categories. This included a zero daily telemedicine share (44.7%), ≤10% share (17.2%), 11-25% share (24.8%), 26-99% share (11.1%), and 100% share (2.2%). The mean overall visit volume included 13.9 visits per day.

Upon analysis, all outcomes demonstrated statistically significant differences across telemedicine share levels. The mean documentation times for PCPs were 71.3 minutes on zero-telemedicine days and 87.1 minutes on days with up to 10% telemedicine visits.

After performing regression model analyses, Apathy and colleagues found days with a mix of visit modalities were associated with a significantly increased time for EHR, documentation, and medical record review.

Compared with zero-telemedicine days, 26-99% telemedicine days were associated with 14.8 (95% CI, 7.6 - 22.0) more minutes of active EHR time (5.6% increase; P <.001), 4.7 (95% CI, 1.2 - 8.3) minutes of additional documentation (6.0% increased; P = .01), and 5.5 (95% CI, 2.8 - 8.2) additional minutes of medical record review (6.2% increase; P <.001). However, telemedicine share showed little rise in order time and no association with next-day documentation time.

Apathy and colleagues noted the greater time spent on EHRs could be due to increased multitasking during telemedicine visits—contrary to in-person visits, PCPs simultaneously engage with patients and their EHRs during a telemedicine appointment.

“This multitasking may feel more efficient and therefore may not register as “burdensome”; further research should explore whether added EHR time associated with mixed-modality days further burdens PCPs,” they wrote.

References

1. _{Apathy NC, Zabala G, Gomes K, Spaar P, Krevat SA, Ratwani RM. Telemedicine and In-Person Visit Modality Mix and Electronic Health Record Use in Primary Care. JAMA Netw Open. 2024;7(4):e248060. doi:10.1001/jamanetworkopen.2024.8060}
2. _{Patel SY, Mehrotra A, Huskamp HA, Uscher-Pines L, Ganguli I, Barnett ML. Trends in Outpatient Care Delivery and Telemedicine During the COVID-19 Pandemic in the US. JAMA Intern Med. 2021;181(3):388-391. doi:10.1001/jamainternmed.2020.5928}
3. _{Holmgren AJ, Thombley R, Sinsky CA, Adler-Milstein J. Changes in Physician Electronic Health Record Use With the Expansion of Telemedicine. JAMA Intern Med. 2023;183(12):1357–1365. doi:10.1001/jamainternmed.2023.5738}