153% surge in patient portal messaging imperils provider workloads

COVID heralded a patient portal renaissance

In response to what felt like the uncontrollable spread of the COVID-19 virus, the nation's public health infrastructure encouraged virtual modalities for care whenever possible. This guidance gave rise to the nation's telehealth boom, which arguably busted later on.

COVID also gave rise to more patient portal utilization, which this latest report indicates continued to flourish once pandemic restrictions lifted.

Leveraging data about patient portal, telephone, telehealth and in-person office visits at 2,067 hospitals and 47,100 clinics between 2020 and 2025, the researchers concluded that the patient portal has become an instrumental supplement to typical care modalities.

During the study period, the number of active patient portal users increased from 94.3 million to 140.5 million. That coincided with the remarkable rise in patient-authored portal messages, totaling 1.34 billion during the five-year period.

But it's not just that more patients are sending messages; the typical individual patient is also sending a higher volume of messages on their own, the researchers said. In 2020, the typical patient sent 0.99 portal messages per year. By 2025, that figure had risen to 2.5 messages per patient per year.

And with more patients sending more messages, staff had more notes to return.

Overall, there were 3.25 billion clinician- and staff-authored patient portal messages during the study period, with clinicians left messaging more patients more often. In 2020, clinicians typically sent 2.2 messages per sender per year. By study's end, that number had risen to 5.4 messages per sender per year.

But an increase in patient portal messaging did not mean a decrease in in-person or telephone care, the researchers pointed out. Indeed, between 2020 and 2025, there was a 17% increase in in-person visits, and any observed dip in telephone encounters was relatively modest at 6%.

In other words, patient portal messaging hasn't replaced in-person or telephone care access. Rather, it's supplemental, meaning it is adding to already crowded provider workloads.

Patient portal messaging shifts healthcare delivery paradigm

In an editor's note, Melanie Molina, M.D., a JAMA editorial fellow and physician at the University of California, San Francisco, joined JAMA Deputy Editor Joseph S. Ross, M.D., in discussing the implications patient portal messaging can have for healthcare delivery.

"The operational implications are immediate: health systems must account for message volume in staffing models, explicitly allocate time for inbox management within clinician schedules, and redesign workflows to integrate asynchronous care alongside visits," the pair wrote. "Failure to do so risks further shifting uncompensated, after-hours work onto clinicians or leaving patient attempts to contact their clinicians to go unanswered."

Health systems will also need to consider infrastructure updates, including triage capabilities, team-based inbox management and decision support tools. This will help manage inbox volume and message complexity.

There have been some industry efforts to mitigate growing portal inboxes and provider burden. For example, CMS introduced a mechanism by which providers could bill for patient portal messages that met certain criteria, such as time spent responding. This billing practice became more widespread during the pandemic.

However, as more organizations consider billing for patient portal messaging, more clarity will be needed to determine which types of messages should qualify for payment.

There is also a health equity concern at play, Molina and Ross mentioned. According to the data, patient portal messaging is more common among patients aged 40-64 who live in areas with lower social vulnerability scores. Health systems should prepare to evaluate their current patient portal policies to account for health disparities.

And none of this is to mention the elephant in the room: AI.

Patient-facing AI, from commercial products like ChatGPT to those developed for a specific provider, has changed how patients seek health information. More specifically, some organizations have implemented LLMs in patient portal messaging either to help clinicians draft responses or to even function as a chatbot for patients.

These innovations, too, need further exploration to ensure efficiency doesn't compromise patient safety.

"Aligning staffing, reimbursement, technology, and quality oversight with this new landscape will be essential to ensure that electronic communication does not contribute to clinician burnout; is appropriately reimbursed; and supports high-quality, equitable care," Molina and Ross concluded.

Sara Heath is an executive editor at Xtelligent Healthcare Media, where she covers patient engagement, healthcare policy and health IT.