Patient portal messages have increased more than 150% in the last five years, according to new findings from the Journal of the American Medical Association (JAMA) – a reality some physicians are managing with the help of artificial intelligence (AI).
The Texas Medical Association has educational resources available (under Managing the Inbox) to help physicians find inbox solutions that work for their practices, including customizable inbox policies and procedures ready for download now.
JAMA’s analysis examined electronic health record (EHR) communications across 2,067 hospitals and 47,100 clinics throughout the nation between 2020 and 2025, a span that began during the COVID-19 pandemic. While office visits increased 17% during that period, messaging volume grew far faster, with practices seeing a 153% increase in messages from patients. Telephone communication, meanwhile, decreased by 6%.
According to the study, one explanation for the high volume of messages is that the patient portal now serves as a primary communication channel patients rely on for between-visit care. That adds more work without proportional compensation, says Todd Richwine, DO, a Fort Worth family physician for Texas Health Family Care and consultant to TMA’s Committee on Health Information Technology and Augmented Intelligence.
Responding to patient-initiated messages, sometimes referred to as an e-visit, can be payable if the response requires at least five minutes of medical decision-making and involves an established patient seen in the clinic within the past three years, among other conditions detailed in the American Medical Association’s STEPS Forward toolkit and by the Centers for Medicare & Medicaid Services.
Even when those conditions are met, physicians cannot bill for responding to a message if the patient had a visit for the condition they are inquiring about in the previous seven days or if the message results in an appointment for the same condition in the subsequent seven days.
“It’s a significant burden, but in today’s world, this is one more way for physicians to effectively care for patients,” Dr. Richwine said. “Physicians go into medicine because we want to help people. This is just a shift in the way we do that. My grandfather was a physician, and everybody in the community knew him. That relationship has shifted, but it doesn't mean it’s degraded. It’s just different now.”
As Texas Health Physicians Group chief medical informatics officer, Dr. Richwine sees inbox burden from a systemic perspectiveas well as a personal one. He credits solutions like inbox triage, boundary setting, and AI-assisted workarounds for decreasing the amount of time physicians in his organization spend in the in-basket.
He also sits on his organization’s AI oversight committee, whose guidelines reflect what TMA has asserted for years: that AI should be used as an augmented toolset under physician review.
Dr. Richwine said his organization built in a “hard stop” that requires physicians to open, review, and individually sign off on communication before it goes to the patient.
The AI system, built into his organization’s EHR system, identifies notes that could be handled by medical assistants and alerts physicians when messages need their review.
To ensure physicians aren’t overwhelmed by e-communications, Dr. Richwine’s practice utilizes a shared messaging pool in the EHR that allows multiple users to work on the same set of messages, lab results, or tasks without flooding physicians’ private inboxes. When a patient sends a message, that communication is screened by the EHR’s integrated AI tool and flags it based on its level of complexity.
He prefers using EHR-integrated tools because they are HIPAA-compliant and emphasizes patients’ protected health information should never be entered into generic AI platforms.
Dr. Richwine also recognizes small and solo practices may not be able to access EHR systems with AI integration. He advises those physicians to create a protocol on how to handle the inbox, such as when to reply to a message immediately or when to delegate to staff – a recommendation TMA policy echoes. He also suggests setting appropriate boundaries, such as scheduling follow-up appointments when necessary.
“It is acceptable to say it is not good care to handle certain things through a patient message,” he said.
Check with your EHR vendor to see if there are opportunities on the horizon to use AI for inbox management.
The AMA STEPS Forward tool-kit also recommends physicians:
- Communicate expectations to patients for response times for different types of messages;
- Consider character limits and restricting messages from patients who aren’t active with the physician, such as those who haven’t had a visit in last one or two years and who do not have one scheduled;
- Anticipate patients’ needs by sending out test results and after-visit summaries automatically, or by ensuring medications are refilled at annual visits; and
- Bill for messages that require clinical decision-making, information AMA’s toolkit provides.
For more information on AI, see TMA’s dedicated webpage.
Alisa Pierce
Reporter, Division of Communications and Marketing
(512) 370-1469