Uptick in Patient Messages May Increase Physician Burnout

Oct. 18, 2021

In a Research Letter from JAMA Network Open, the authors analyzed trends in EHR inbox messaging during COVID-19, finding an increase in patient messaging merits further exploration about pandemic-related medical advice requests

Janette Wider

In an Oct. 12 Research Letter from JAMA Network Open entitled, “Trends in Electronic Health Record Inbox Messaging During the COVID-19 Pandemic in an Ambulatory Practice Network in New England,” the authors address COVID-19 related disruptions regarding how patients access routine care. They explain that anecdotal evidence indicates that ambulatory physicians saw an increase in patient medical advice requests (PMARs) and they compared patient message volume during the pandemic with levels pre-pandemic.

The letter states that “This cross-sectional study analyzed deidentified electronic health record metadata (Signal, Epic Systems) from March 2018 to June 2021 in a large ambulatory practice network in New England. This study was deemed exempt for review and informed consent by Yale University’s institutional review board because it involves secondary research of deidentified electronic health record metadata that did not include any patient identifier or private health information. This study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.”

That said, “Trends in inbox message volume (categorized by message type and source), time in the inbox, visit volume and type (in-person vs telehealth), patient volume, and patient use of the patient portal were examined using descriptive statistics. Physician specialties were grouped into primary care, medical, and surgical specialties. Variables were compared before (March 2018 to February 2020) and during (March 2020 to June 2021) the COVID-19 pandemic. To assess whether the onset of the pandemic was an inflection point in PMARs, message volume per physician per day was modeled by piecewise linear regression using a spline for month with a single knot at March 2020 and Huber-White SEs. Three months of inbox message data were missing (3 of 40 months [7.5 percent]) and excluded from the analysis. To test for significance (P < .05), we used a 2-sided Wald test for equivalence of the coefficients. We used Stata statistical software version 16 (StataCorp) for data analyses.”

The authors explain that forty months of inbox messages were analyzed—including 10,850,401 messages to 419 unique physicians from 38 specialties across 141 practice sites.

Between March 2020 and June 2021, the average total messages per day increased from:

45.0 to 46.0 for primary care physicians
29.3 to 32.0 for medical physicians
16.6 to 23.3. for surgical physicians

The authors write that “Consistent with national trends, during 2020 COVID months, monthly in-person visits decreased for all specialties (primary care, 17.1 percent; medical, 18.5 percent; surgical, 7.7 percent), whereas telehealth visits increased. Surgical specialties, however, experienced an increase in in-person visits between January and June 2021. The number of unique patients seeking care during the pandemic decreased for primary care and medical specialties through June 2021 but increased for surgical specialties in 2021.”

The authors comment that during the first 15 months of the pandemic the increase in patient message volume was small but sustained, particularly in PMARs, across all specialties, despite the decrease (for primary care and medical physicians) in the number of patients seeking care during the same period. The increase in surgical patients in 2021 could be attributed to the backlog of elective surgeries that were delayed in 2020.

The authors conclude that “Given the existing physician burnout crisis and the already known pandemic-related stressors and risks to the physician workforce, the additional inbox burden reported here warrants additional exploration to assess the nature of pandemic-related medical advice requests and the generalizability of these findings. With COVID-19 potentially remaining a long-term endemic threat to public health, the priority to systematically address inbox burden before the pandemic through workflow redesign, team-based inbox management, and consideration of reimbursement for inbox-related work remains.”