Brave New Telemedicine: Cognitive Bias and the Anticoagulant Gap in Atrial Fibrillation Care

Abstract

Telemedicine has transformed healthcare delivery, yet its impact on the quality and consistency of clinical decision-making remains underexplored in operations management. While heralded for efficiency and access, it is unclear whether virtual care systematically alters adherence to clinical practice guidelines. This study investigates whether the mode of care, telemedicine versus in-person, affects clinicians’ guideline-recommended prescribing of anticoagulants for atrial fibrillation, where treatment adherence is crucial to prevent severe outcomes. Using electronic medical record data from 16,603 patient encounters at a major academic health system in the United States (2020–2023), we employ a two-way fixed-effects linear probability model to compare prescribing patterns. We find that telemedicine visits are associated with a 5.2-percentage-point lower probability of guideline-recommended anticoagulant prescription than in-person visits. The gap is driven by clinicians with historically lower adherence; top-quartile clinicians show no difference across modalities, exhibiting behavioral robustness (adherence resilient to modality). We propose that telemedicine’s leaner information channel heightens perceived uncertainty, activating cognitive biases: For some clinicians, telemedicine exacerbates ambiguity aversion and omission bias, favoring inaction in virtual settings. Linking service design to variation in professional judgment, we show how operational context moderates decision quality. Practically, healthcare organizations should not treat telemedicine as a simple substitute for in-person care; they should implement targeted operational interventions, such as enhanced decision support and training on cognitive biases, to maintain high standards of care so efficiency and access gains do not come at the cost of adherence. In a supplementary analysis, we estimate that, at the population level in the United States, a 5.2-percentage-point telemedicine-related gap in anticoagulant prescribing could result in more than 150 preventable strokes and roughly $50 million in avoidable lifetime costs annually for each newly diagnosed cohort, underscoring its substantial clinical and economic significance.