Electronic health records (EHRs) make providing coordinated, efficient care easier and reduce medical errors and test duplications; research has also correlated EHR adoption with higher patient satisfaction and outcomes. However, for physicians, the benefits come at a cost.
Physicians spend significantly more time in healthcare portals, making notes, entering orders, reviewing clinical reports, and responding to patient messages.
"I spend at least the same amount of time in the portal that I do in scheduled clinical time with patients," said Eve Rittenberg, MD, primary care physician at Brigham and Women's Hospital and assistant professor at Harvard Medical School, Boston, Massachusetts. "So, if I have a 4-hour session of seeing patients, I spend at least another 4 or more hours in the patient portal."
The latest data showed that primary care physicians logged a median of 36.2 minutes in the healthcare portal per patient visit, spending 58.9% more time on orders, 24.4% more time reading and responding to messages, and 13% more time on chart review compared to pre-pandemic portal use.
"EHRs can be very powerful tools," said Ralph DeBiasi, MD, a clinical cardiac electrophysiologist at Yale New Haven Health. "We're still working on how to best harness that power to make us better doctors and better care teams and to take better care of our patients because their use can take up a lot of time."
Portal Time Isn't Paid Time
Sharp increases in the amount of time spent in the EHR responding to messages or dispensing medical advice via the portal often aren't linked to increases in compensation; most portal time is unpaid.
"There isn't specific time allocated to working in the portal; it's either done in the office while a patient is sitting in an exam room or in the mornings and evenings outside of traditional working hours," DeBiasi told Medscape Medical News. "I think it's reasonable to consider it being reimbursed because we're taking our time and effort and making decisions to help the patient."
Compensation for portal time affects all physicians, but the degree of impact depends on their specialties. Primary care physicians spent significantly more daily and after-hours time in the EHR, entering notes and orders, and doing clinical reviews compared to surgical and medical specialties.
In addition to the outsized impact on primary care, physician compensation for portal time is also an equity issue.
Rittenberg researched the issue and found a higher volume of communication from both patients and staff to female physicians than male physicians. As a result, female physicians spend 41.4 minutes more on the EHR than their male counterparts, which equates to more unpaid time. It's likely no coincidence then that burnout rates are also higher among female physicians, who also leave the clinical workforce in higher numbers, especially in primary care.
"Finding ways to fairly compensate physicians for their work also will address some of the equity issues in workload and the consequences," Rittenberg said.
Addressing the Issue
Some health systems have started charging patients who seek medical advice via patient portals, equating the communication to asynchronous acute care or an additional care touchpoint and billing based on the length and complexity of the messages. Patient fees for seeking medical advice via portals vary widely depending on their health system and insurance.
At University of California San Francisco Health, billing patients for EHR communication led to a sharp decrease in patient messages, which eased physician workload. At Cleveland Clinic, physicians receive "productivity credits" for the time spent in the EHR that can be used to reduce their clinic hours (but have no impact on their compensation).
Changes to the Medicare Physician Fee Schedule also allow physicians to bill for "digital evaluation and management" based on the time spent in an EHR responding to patient-initiated questions and requests.
However, more efforts are needed to ease burnout and reverse the number of physicians who are seeing fewer patients or leaving medical practice altogether as a direct result of spending increasing amounts of unpaid time in the EHR. Rittenberg, who spends an estimated 50% of her working hours in the portal, had to reduce her clinical workload by 25% due to such heavy portal requirements.
"The workload has become unsustainable," she said. "The work has undergone a dramatic change over the past decade, and the compensation system has not kept up with that change."
Prioritizing Patient and Physician Experiences
The ever-expanding use of EHR is a result of their value as a healthcare tool. Data showed that the electronic exchange of information between patients and physicians improves diagnostics, reduces medical errors, enhances communication, and leads to more patient-centered care — and physicians want their patients to use the portal to maximize their healthcare.
"[The EHR] is good for patients," said DeBiasi. "Sometimes, patients have access issues with healthcare, whether that's not knowing what number to call or getting the right message to the right person at the right office. If [the portal] is good for them and helps them get access to care, we should embrace that and figure out a way to work it into our day-to-day schedules."
But maximizing the patient experience shouldn't come at the physicians' expense. Rittenberg advocates a model that compensates physicians for the time spent in the EHR and prioritizes a team approach to rebalance the EHR workload to ensure that physicians aren't devoting too much time to administrative tasks and can, instead, focus their time on clinical tasks.
"The way in which we provide healthcare has fundamentally shifted, and compensation models need to reflect that new reality," Rittenberg added.
Jodi Helmer is a freelance journalist who writes about health and wellness for Fortune, AARP, WebMD, Fitbit, and GE Health.