Click to Enlarge: Burnout, video visits, and secure messages among Veterans Health Administration primary care providers by fiscal year. The figure depicts annual averages with 95% CIs at the health care system level. (A) Unadjusted trend of burnout by year. (B) Unadjusted trend of video visits and secure messages by year.
Source: Journal of Medical Internet Research
LOS ANGELES — Increasing numbers of secure patient messages are overwhelming primary-care providers in the VA health system and appear to be leading to clinician burnout, according to new research.
Among other metrics, the median annual secure messages per 1,000 patients increased by 50% from 23.4 in FY 2020 to 35.3 in FY 2023 in the study of 138 VHA healthcare systems.
Different telehealth services can have varying effects on primary-care provider burnout, noted the study published in the Journal of Medical Internet Research. While primary-care provider burnout isn’t associated with telehealth video visit volumes in the VA healthcare system, secure patient message volumes were found to be linked to burnout.
Led by the VA Greater Los Angeles Healthcare System, the researchers examined the associations between primary-care provider burnout and the volumes of video visits and secure patient messages within the healthcare systems where these primary-care providers practiced.1
“People often think of telehealth as a panacea to all problems in healthcare, especially after it was widely rolled out during the COVID-19 pandemic,” Eric Apaydin, PhD, , a research health scientist at the Center for Study of Healthcare Innovation, Implementation and Policy (CSHIIP) at the VA Greater Los Angeles Healthcare System, told U.S. Medicine. “We wanted to see if some types of telehealth had unintended effects on provider working lives and found that secure messages were related to increased burnout, while video visits were not.”
Burnout among primary-care providers in the United States has been continually high for years, with key factors including excessive workloads or work hours and high clerical or administrative burden associated with electronic healthcare record systems. During the COVID-19 pandemic, telehealth use, such as synchronous video visits and asynchronous secure patient messages, expanded significantly in the VA healthcare system. Primary-care provider burnout also increased during this time, the researchers explained.
During the early pandemic, studies have found that video visits increased by 2 to 6 times, and secure-message use increased by about 50%. Even when in-person care stabilized in 2023, patients attended about 60,000 video primary-care visits per month in the VA healthcare system. Video visits can serve as substitutes to in-person visits, and secure messaging may complement or add to video, phone or in-person visits. Though patients are generally satisfied with telehealth services in primary care, the views of primary-care providers about these technologies are mixed.
In this study, the researchers examined the associations between telehealth modalities (video visits and secure messages) and burnout as reported by 17,034 primary-care providers in 138 healthcare systems in the VHA from 2020 to 2023. They obtained individual-level data from annual cross-sectional surveys and healthcare system-level data from the Corporate Data Warehouse (CDW) and VHA All Employee Survey. Since telehealth use varies in the VA health care system, the investigators assessed telehealth use at the health-care system level to account for differences in policies, personnel and preferences.
Using statistical analyses, the research team evaluated the relationships between individual-level primary-care provider burnout and average volumes of health-care system-level video visits and secure messages per 1,000 patients. The study controlled for age, sex, race or ethnicity, VHA tenure and healthcare system complexity and year.
This study is the first and largest national analysis of telehealth use and burnout in primary care.
“People often overlook small aspects of workflow and work design when trying to understand the drivers of burnout in healthcare,” Apaydin said. “Here, we show that increasing secure message volume, but not video visit volume, is associated with higher VA primary care burnout. Findings suggest that telehealth modality may be important for provider well-being. It’s possible that having more support when starting video visits helped reduce burnout, especially compared to how secure messaging was introduced. Small changes, like managing secure message inboxes with AI, working collaboratively with ancillary staff to answer messages, or encouraging patients to schedule video appointments rather than send messages, could go a long way to reducing burnout in primary care.”
Nearly 50% of primary-care providers were burned out during the study period, and that burnout increased from 42.1% in FY 2020 to 52.7% in FY 2023 across repeated, annual cross-sections. Across all years, burnout was generally higher among middle-age (40‐59 years old), white, female and early career primary-care providers, as well as among those who worked in less-complex healthcare systems, the researchers pointed out.
Over the 4-year study period, the median annual video visits per 1,000 patients in healthcare systems increased from 15.9 to 227.6. The median annual secure messages per 1,000 patients increased by 50% from 23.4 in FY 2020 to 35.3 in FY 2023. Video visits peaked in FY 2021 (median 251.5, IQR 157.4‐279.7 per 1,000 patients), and secure messages peaked in FY 2022 (median 46.8, IQR 16.5‐127.8 per 1,000 patients) across healthcare systems. In fully adjusted models, video visit volumes in a healthcare system weren’t related to burnout, but secure message volumes were related to burnout, according to the study.
Burnout was significantly higher among primary-care providers in healthcare systems receiving additional secure messages per 1,000 patients (odds ratio 1.001, 95% CI 1.000-1.002). On average, primary-care provider burnout increased by 1% point for each additional increase of 43.7 (95% CI 14.0-73.4) secure messages in a healthcare system, the investigators reported.
During the entire study period, the median video visit volume was 183.2 (IQR 66.9‐323.0) per 1,000 patients, and the median secure message volume was 37.8 (IQR 13.7‐92.93) per 1,000 patients.
“This research might encourage primary care clinicians to take a closer look at how their clinics handle patient messages and to speak up for better support and new tools to help manage them more effectively,” Apaydin said.
- Apaydin EA, Der-Martirosian C, Yoo C, Rose DE, Jackson NJ, Stockdale SE, Leung LB. Secure Messages, Video Visits, and Burnout Among Primary Care Providers in the Veterans Health Administration: National Survey Study. J Med Internet Res. 2025 Sep 5;27:e68858. doi: 10.2196/68858. PMID: 40911914; PMCID: PMC12413187.
