Patient Portal Messages Outpace Office Visits

Patient-authored portal messages surged 153% between 2020 and 2025, far outpacing growth in office visits and effectively creating a largely uncompensated layer of care that health systems and payers have yet to fully account for, according to a large cross-sectional study and editorial published online today in JAMA.^1,2

Drawn from approximately 8 billion encounters aggregated through Epic Cosmos across more than 2000 hospitals and 47,000 clinics, the analysis found that patient-authored messages climbed from 0.99 to 2.50 per active patient per year (PPPY) over the study period. Office visits rose 17%, from 2.37 to 2.77 PPPY, while telephone encounters among active patients fell 6% and among message senders by 7%. Overall, the increase in messaging was not associated with a decrease in office visits, leading authors to posit that health systems are now managing a third, additive communication channel alongside traditional modalities.²

What Do the Data Reveal About Messaging Volume and Clinician Burden?

Breaking the encounters down, there were 1.77 billion office visits, 1.34 billion patient-authored and 3.25 billion clinician- and staff-authored messages, 1.59 billion telephone encounters, and 146 million telehealth encounters. Among the 139,408,600 million active patients in the dataset as of Q1 2025, 30% (41.8 million) sent at least 1 portal message during the quarter. Messaging intensity among senders also more than doubled over the study period: from 2.2 to 5.4 messages per sender per year, representing a 146% increase. Clinician- and staff-authored messages also grew, rising 24% to 5.70 per patient per year, with a peak of 6.86 during the COVID-19 pandemic before partially receding.

Together, these data point to a structural increase in total communication on both sides of the patient-clinician relationship, with no corresponding reduction in office visits or telephone encounters to offset the added workload.

Previous research shows the operational implications of rising electronic health record (EHR) inbox demands, including that more than 30% of patient-initiated EHR messages involve administrative rather than clinical content.³

For managed care organizations and health systems negotiating staffing models and value-based contracts, these JAMA findings underscore a structural misalignment: Messaging has become a core component of care delivery, but most reimbursement frameworks were not designed to account for it. As health systems begin billing select portal interactions as e-visits using Current Procedural Terminology codes 99421 through 99423, clarity on which message types qualify and whether reimbursement keeps pace with actual clinician time is increasingly urgent.

Are Equity Gaps Persisting as Messaging Becomes a Primary Modality?

The demographic breakdown of message senders points to an entrenched digital divide. Messaging prevalence was highest among patients aged 40 to 64 (35.1%), women vs men (33.0% vs 26.1%), and those in the lowest Social Vulnerability Index (SVI) quartile (36.7% vs 25.2% in the highest SVI quartile). Rural (28.5%) and micropolitan (28.3%) patients also lagged behind their urban counterparts. Here, research has previously documented this divide. A study of more than 250,000 adults with chronic conditions found lower portal engagement among older, non–English-speaking, and Black patients.⁴

As portal messaging increasingly begins to “function as an expansion of between-visit care rather than a substitute for in-person care,” the study authors note that health care systems may need to plan not only for increased messaging volume but also for addressing engagement gaps among underserved populations.¹ The accompanying editorial echoes their concern, noting that “further work is needed to characterize the structural drivers of these disparities and ensure equitable access and response times.”²

What Comes Next for Health Systems and Payers?

The editorial’s authors flag the deployment of generative artificial intelligence tools for drafting and triaging messages as an area requiring scrutiny, calling for evaluation of downstream effects on care quality, patient trust, and clinician workload before widespread adoption.²

For health systems and payers, the JAMA research concludes with a direct charge to health systems^1,2: Staffing models must account for message volume, time for inbox management must be built into clinician schedules, and reimbursement must be aligned with the effort messaging now demands. Without these changes, the authors of both warn, uncompensated after-hours work will continue to fall on clinicians, or patient messages could go unanswered.

References

1. Long JJ, McAdams-DeMarco MA, Schwartz MD, et al. Trends in patient portal messages, office visits, and telephone encounters. JAMA. Published online June 22, 2026. doi:10.1001/jama.2026.8690
2. Molina M, Ross JS. National trends in patient messaging—the growing electronic inbox. JAMA. Published online June 22, 2026. doi:10.1001/jama.2026.8646
3. Escribe C, Eisenstat SA, O’Donnell WJ, Levi R. Understanding physicians' work via text analytics on EHR inbox messages. Am J Manag Care. 2022;28(1):e24-e30. doi:10.37765/ajmc.2022.88817
4. Ali MM, Lunos S, Henderson Z, et al. Insights into patient portal engagement leveraging observational electronic health data. Am J Manag Care. 2026;32(1):42-48. doi:10.37765/ajmc.2026.89870