Research Letter
Physician Work Environment and Well-Being
February 24, 2025
Trends in Physician Electronic Health Record Time and Message Volume
A Jay Holmgren, Nate C. Apathy, Christine A. Sinsky, et al
JAMA Intern Med. Published online February 24, 2025. doi:10.1001/jamainternmed.2024.8138
Physician work is increasingly centered around the electronic health record (EHR), which consumes nearly 50% of scheduled clinic time.1 Time spent in the EHR and inbox has been associated with burnout.2,3 Patient-initiated medical advice request messages increased substantially at the onset of the COVID-19 pandemic as other forms of care access were limited.4However, it is unclear how durable the post–COVID-19 increase in patient medical advice request volume has been, whether the rise in messages represents a substitution from other communication modalities (eg, telephone calls), the distribution of this increase across specialties, and the resulting impact on total EHR time. To address these questions and guide health system and policymaker efforts to address inbox burden, we used national EHR metadata to assess how patient medical advice request inbox work and EHR time changed from 2019 to 2022.
Methods
We used national Epic Signal measures, which are monthly aggregations of granular, physician-level EHR use metadata, including EHR time and number of messages received.5 This dataset includes deidentified measures for all ambulatory physicians (280 712 unique physicians) using an Epic EHR in the US from June 2019 through March 2022. Measures were normalized to weekly averages.
We measured weekly patient medical advice request message volume, including messages sent or forwarded to the physician’s inbox and messages sent to shared inboxes that were then completed by the physician. We also measured the volume of patient telephone calls forwarded to physician inboxes. We then measured active EHR time, defined in Signal as time performing tasks, including mouse movement, clicks, or keystrokes, excluding time following 5 seconds of inactivity. EHR time was categorized as during clinic hours, beginning 30 minutes prior to the first appointment through 30 minutes following the last appointment, and time outside scheduled patient hours on days with appointments and time on unscheduled days.6
We used descriptive statistics to measure mean patient medical advice request volume and patient telephone call volume over time, stratified by physician specialty groupings.5 We compared mean EHR time between the pre–COVID-19 period (June 2019-February 2020) to the post–COVID-19 onset period (March 2020-April 2022). We also performed sensitivity tests, including only physicians with greater than 40 visits per week to assess trends among physicians with substantial clinical volume.
This study was deemed nonhuman participant research by the University of California, San Francisco institutional review board self-certification process. This study followed STROBEreporting guidelines.
Results
Patient medical advice request messages and patient telephone calls rose in March 2020 across specialty groups. Primary care physicians (PCPs) received the most, with a mean of 24 patient calls and 16 patient medical advice request messages per week (Figure 1A), with similar trends between the full sample and the subset of physicians with at least 40 visits per week (Figure 1B).
Mean time actively working in the EHR per week increased for all specialty groups following the onset of the COVID-19 pandemic (Figure 2A). PCP EHR time increased 6.5%, from a mean of 10.6 to 11.3 hours per week, medical subspecialists’ time increased 9.9%, and surgeons’ time increased 5.2%. Physicians with greater than 40 visits per week saw similar trends, with PCPs having the highest EHR time before and after the start of the pandemic (7.8% increase from 14.1 to 15.2 hours per week; Figure 2B).
Discussion
The volume of EHR messages received by physicians increased at the onset of the COVID-19 pandemic in March 2020 and remained elevated. Patient medical advice request messages meaningfully increased, and we found no evidence that patients were substituting other communication, such as telephone calls, which stabilized at prepandemic levels. Study limitations include data from a single EHR vendor and inability to evaluate message content or burnout. Nonetheless, these results suggest that the increase in message volume is likely a sustained, ongoing source of physician work. Health systems and policymakers should prioritize strategies to reduce inbox burden for physicians, especially PCPs, while maintaining patient access to care.
