Editor's Note 

February 24, 2025

Patient Portals—Balancing Workload and Opportunity

Ilana B. Richman, Ishani Ganguli, Eve Rittenberg

JAMA Intern Med. Published online February 24, 2025. doi:10.1001/jamainternmed.2024.8135

Soon after the earliest email systems were developed in the late 1960s, electronic messages began to pile up. The onslaught of messages surprised early adopters and spurred the development of message management systems from which modern email applications descended.¹ Sixty years later, health care email has arrived in earnest with the development of patient portal messaging systems. And despite the history, the recent growth of patient portal messaging has caught clinicians and health systems by surprise. As health care systems struggle to adapt, understanding the scale of portal messaging and its potential impacts on clinicians and patients is crucial for designing and implementing effective solutions.

In this issue of JAMA Internal Medicine, Holmgren and colleagues² quantified patient-initiated messages to US physicians using Epic before and after onset of the COVID-19 pandemic. Consistent with studies in smaller populations,³they found that message volumes increased markedly in early 2020 and have persisted at these levels since.² The rise in patient portal messages was coincident with a rise in telephone calls and a substantial increase in time spent in the electronic health record, suggesting that portal messages are additive, rather than replacements for other forms of communication.

While the study by Holmgren and colleagues² frames portal messaging primarily as a challenge, we would emphasize that it is also an opportunity. Through portal messages, patients can report symptoms and adverse effects, ask questions, seek clarification about care plans, and accomplish straightforward tasks like scheduling or requesting refills. Many concerns or questions can be resolved efficiently, particularly when the clinical team knows the patient well. Features like read receipts can ensure closed-loop communication between patients and clinicians. Ultimately, lowering the bar for contacting the health care team could improve patient safety, adherence, and health. Given these benefits, measuring the positive impacts of patient portal messaging on health outcomes is as important as documenting its burden.

This opportunity should also be reflected in efforts to optimize portal messaging. As medicine catches up to other workplaces in adapting to the new reality of patient messaging, proposed solutions tend to focus on reducing message volume for clinicians. This makes some sense given the sheer number of messages, the typical lack of compensation for the work, and the association between message volume and burnout. To this end, clinical leaders have trialed solutions like asking patients to send fewer messages, charging patients for messages, and using artificial intelligence–generated responses.

At the same time, solutions cannot solely be oriented around reducing patient message volume. Instead, we must reimagine patient messaging as a central part of patient care, rather than an add-on task squeezed into the interstices. As such, we should build and equip teams to handle the volume and variety of messages, many of which do not need a physician’s input, and use artificial intelligence and other technology to triage messages appropriately. Payment models should adapt to the reality of patient messaging by considering messaging part of direct patient care and compensate physicians and practices accordingly—ideally through hybrid payment models. Only then can patients benefit from the promise of portal messaging while also ensuring that rising message volumes do not overwhelm clinicians and contribute to burnout.