More Tethered to the EHR: EHR Workload Trends Among Academic Primary Care Physicians, 2019-2023

Brian G. Arndt; Mark A. Micek; Adam Rule; Christina M. Shafer; Jeffrey J. Baltus; Christine A. Sinsky

doi:10.1370/afm.3047

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Figure 1.
Primary care physicians’ average workload by year.
aFTE = ambulatory FTE; FTE = full-time equivalency.
Note: Grey band represents 95% confidence interval.
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Figure 2.
Primary care physicians’ average time in the EHR by year.
EHR = electronic health record; TOSH = time outside scheduled hours on days with scheduled appointments; TUSD = time on unscheduled days.
Note: Time in notes, inbox, orders, clinical review, outside scheduled hours on days with appointments, and on unscheduled days are included in total EHR time. Grey band represents 95% confidence interval.
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Figure 3.
Primary care physicians’ average volume of select inbox message types received by year.
eConsult = electronic consult.
Note: Grey band represents 95% confidence interval.

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Table 1.

Physician Demographics and Workload by Specialty

Characteristic	All Specialties (N = 141)	Family Medicine (N = 70)	Internal Medicine (N = 48)	General Pediatrics (n = 23)	P Value
Sex, No. (%)
Male	47 (33.3)	26 (37.1)	17 (35.4)	4 (17.4)	0.20^{^a}
Female	94 (66.7)	44 (62.9)	31 (64.6)	19 (82.6)
Employment, y, No. (%)
<5	9 (64.9)	6 (8.6)	3 (6.2)	0 (0.00)	0.64^{^a}
5-9	33 (23.4)	16 (22.9)	11 (22.9)	6 (26.1)
10-14	45 (31.9)	25 (35.7)	15 (31.2)	5 (21.7)
15-19	15 (10.6)	7 (10.0)	6 (12.5)	2 (8.7)
≥20	39 (27.7)	16 (22.9)	13 (27.1)	10 (43.5)
Workload, mean (SD)^{^b}
Ambulatory FTE	0.63 (0.21)	0.61 (0.20)	0.65 (0.23)	0.62 (0.18)	0.36^{^c}
Active panel size/ambulatory FTE	2,117.0 (482.0)	2,244.0 (541.0)	1,966.0 (359.0)	2,043.0 (418.0)	0.002^{^c}
Visits/week	31.1 (9.9)	31.4 (9.5)	29.7 (10.7)	33.0 (9.3)	0.45^{^c}
Visits/8-hour clinic	15.1 (2.3)	15.8 (2.2)	13.7 (1.4)	16.0 (2.8)	<.001^{^c}
Hours/week	16.7 (5.3)	16.3 (5.1)	17.3 (6.0)	16.9 (4.6)	0.42^{^c}

FTE = full-time equivalent.
↵a P value from χ² test.
↵b Workload data averaged from April 2022 to March 2023.
↵c P value from Kruskal-Wallis H-test.

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Table 2.

EHR Time and Inbox Message Volume by Study Year

	2019-2020 Mean (SD)^{^a}	2020-2021 Mean (SD)^{^b}	2021-2022 Mean (SD)^{^c}	2022-2023 Mean (SD)^{^d}	Change, 2019-2020 to 2020-2021			Change, 2020-2021 to 2021-2022			Change, 2021-2022 to 2022-2023			Change, 2019-2020 to 2022-2023
	2019-2020 Mean (SD)^{^a}	2020-2021 Mean (SD)^{^b}	2021-2022 Mean (SD)^{^c}	2022-2023 Mean (SD)^{^d}	Obs (%)	Est (95% CI)	P Value^{^e}	Obs (%)	Est (95% CI)	P Value^{^e}	Obs (%)	Est (95% CI)	P Value^{^e}	Obs (%)	Est (95% CI)	P Value^{^e}
Workload
Ambulatory aFTE	0.66 (0.21)	0.65 (0.22)	0.64 (0.22)	0.63 (0.21)	−0.01(−1.8)	−0.01 (−0.01 to −0.01)	<.001	−0.01(−2.0)	−0.01 (−0.02 to −0.01)	<.001	−0.01(−1.4)	−0.01 (−0.01 to −0.01)	<.001	−0.03 (−5.2)	−0.03 (−0.04 to −0.03)	<.001
Active panel/aFTE	2,153.0 (529)	2,202.0 (618)	2,203.0 (614)	2,117.0 (482)	49.0 (2.3)	49.0 (25.0 to 73.0)	<.001	1 (0.0)	2 (−21.0 to 26.0)	0.87	−86 (−3.9)	−92.0 (−116.0 to −69.0)	<.001	−36 (−1.7)	−41.0 (−66.0 to −17.0)	0.001
Visits₈	15.4 (2.9)	13.1 (1.8)	14.4 (2.2)	15.1 (2.3)	−2.2 (−14.5)	−2.3 (−2.4 to −2.1)	<.001	1.3 (9.7)	1.3 (1.2 to 1.5)	<.001	0.7 (4.7)	0.7 (0.5 to 0.8)	<.001	−0.3 (−1.8)	−0.3 (−0.4 to −0.1)	<.001
Visits_Week	33.6 (11.2)	28.7 (9.0)	30.6 (9.8)	31.1 (9.9)	−4.9 (−14.6)	−5.0 (−5.5 to −4.5)	<.001	1.9 (6.5)	1.8 (1.3 to 2.3)	<.001	0.5 (1.7)	0.6 (0.1 to 1.1)	0.01	−2.5 (−7.5)	−2.6 (−3.1 to −2.1)	<.001
Hours_Week	17.7 (5.4)	17.8 (5.5)	17.2 (5.5)	16.7 (5.3)	0.0 (0.2)	0.1 (−0.2 to 0.3)	0.65	−0.5 (−2.9)	−0.6 (−0.8 to −0.4)	<.001	−0.5 (−2.9)	−0.4 (−0.7 to −0.2)	<.001	−1.0 (−5.5)	−1.0 (−1.2 to −0.7)	<.001
EHR time, min per 8 hours scheduled clinic
EHR₈	362.9 (132.9)	366.1 (145.8)	383.6 (150.0)	391.3 (149.1)	3.2 (0.9)	2.2 (−2.3 to 6.7)	0.36	17.5 (4.8)	17.9 (13.5 to 22.2)	<.001	7.7 (2.0)	7.9 (3.5 to 12.3)	0.001	28.4 (7.8)	28.0 (23.5 to 32.5)	<.001
Notes₈	124.6 (73.4)	122.0 (79.1)	129.0 (79.4)	127.5 (78.5)	−2.6 (−2.1)	−2.9 (−5.1 to −0.8)	0.009	6.9 (5.7)	7.2 (5.1 to 9.2)	<.001	−1.4 (−1.1)	−1.2 (−3.3 to 0.9)	0.28	2.9 (2.3)	3.0 (0.8 to 5.1)	0.008
Inbox₈	57.4 (24.9)	67.1 (30.7)	73.6 (34.4)	71.4 (32.4)	9.6 (16.8)	8.9 (7.6 to 10.2)	<.001	6.6 (9.8)	7.1 (5.8 to 8.3)	<.001	−2.2 (−3.0)	−3.1 (−4.3 to −1.8)	<.001	14.0 (24.4)	12.9 (11.6 to 14.2)	<.001
Orders₈	39.2 (13.2)	46.3 (19.6)	57.6 (24.3)	62.4 (25.2)	7.1 (18.1)	6.5 (5.6 to 7.3)	<.001	11.3 (24.4)	11.6 (10.8 to 12.3)	<.001	4.7 (8.2)	4.7 (3.9 to 5.4)	<.001	23.1 (58.9)	22.7 (21.9 to 23.5)	<.001
Review₈	55.4 (25.4)	62.5 (30.3)	63.5 (31.0)	62.6 (30.2)	7.1 (12.9)	6.9 (5.9 to 7.8)	<.001	1.0 (1.5)	1.0 (0.1 to 1.9)	0.03	−0.9 (−1.4)	−1.0 (−1.9 to −0.1)	0.03	7.2 (13.0)	6.9 (5.9 to 7.8)	<.001
TOSH₈	77.9 (54.7)	77.2 (54.2)	81.6 (58.2)	84.3 (58.8)	−0.8 (−1.0)	−1.1 (−3.1 to 0.9)	0.30	4.4 (5.7)	4.5 (2.6 to 6.4)	<.001	2.7 (3.3)	2.7 (0.8 to 4.6)	0.008	6.4 (8.2)	6.1 (4.1 to 8.1)	<.001
TUSD₈	68.2 (61.8)	75.5 (75.7)	80.5 (76.2)	81.8 (77.2)	7.3 (10.7)	6.9 (3.9 to 9.9)	<.001	5.0 (6.6)	5.2 (2.4 to 8.1)	<.001	1.3 (1.6)	1.2 (−1.7 to 4.0)	0.46	13.6 (19.9)	13.3 (10.3 to 16.3)	<.001
Inbox volume (messages)
Patient calls	26.2 (12.1)	25.5 (11.1)	24.9 (10.3)	23.5 (9.6)	−0.8 (−3.0)	−0.6 (−1.1 to −0.1)	0.01	−0.6 (−2.3)	−0.6 (−1.1 to −0.2)	0.01	−1.4 (−5.6)	−1.3 (−1.8 to −0.9)	<.001	−2.8 (−10.5)	−2.6 (−3.1 to −2.1)	<.001
Rx₈	12.0 (7.8)	13.7 (8.7)	14.7 (9.7)	14.3 (8.5)	1.7 (14.4)	1.7 (1.3 to 2.0)	<.001	1.0 (7.2)	1.0 (0.7 to 1.4)	<.001	−0.4 (−2.6)	−0.5 (−0.8 to −0.1)	0.006	2.3 (19.5)	2.2 (1.9 to 2.6)	<.001
Results₈	12.6 (6.1)	11.0 (5.2)	12.2 (5.3)	12.3 (5.1)	−1.6 (−12.5)	−1.6 (−1.8 to −1.4)	<.001	1.2 (10.5)	1.2 (1.0 to 1.4)	<.001	0.1 (0.6)	0.0 (−0.2 to 0.3)	0.72	−0.3 (−2.7)	−0.4 (−0.6 to −0.2)	0.001
MyChart₈	9.8 (5.9)	14.4 (7.8)	15.1 (7.9)	15.3 (7.6)	4.6 (47.2)	4.5 (4.2 to 4.8)	<.001	0.7 (4.7)	0.7 (0.4 to 1.1)	<.001	0.1 (0.9)	0.0 (−0.3 to 0.3)	0.88	5.4 (55.5)	5.3 (5.0 to 5.6)	<.001
eConsult₈	0.19 (0.2)	0.24 (0.25)	0.27 (0.3)	0.31 (0.3)	0.04 (23.0)	0.04 (0.02 to 0.06)	<.001	0.03 (13.9)	0.04 (0.02 to 0.05)	<.001	0.04 (14.9)	0.03 (0.02 to 0.05)	<.001	0.12 (61.0)	0.11 (0.09 to 0.12)	<.001

8 = per 8 hours of scheduled clinic appointments; aFTE = ambulatory FTE; eConsult = electronic consult; EHR = electronic health record; Est = model estimate; FTE = full-time equivalency;
Obs = observed; Rx = medical prescription; TOSH = time outside scheduled hours on days with scheduled appointments; TUSD = time on unscheduled days.
↵a May 2019 to February 2020.
↵b June 2020 to March 2021.
↵c May 2021 to March 2022.
↵d April 2022 to March 2023.
↵e P values adjusted by Benjamini-Hochberg procedure to limit false discovery rate to 5%.