How 5 health systems reined in patient portal messages

Health system chief medical information officers told Becker's they've reduced patient portal messages for physicians with the help of both human colleagues and artificial intelligence.

Clinicians' inboxes have been flooded with messages since the shift to telehealth accelerated by the pandemic, as patients became comfortable messaging their providers online about everything from medication refills to new symptoms. Physicians spend 14 more minutes in their inboxes compared to the year before the pandemic, including after hours and on their days off, according to a February study in Annals of Family Medicine.

"The good news is that we have been successful at engaging our patients to stay in better contact with us, but many of us were not operationally prepared for the significant increase in time that needs to be spent addressing these messages," said Neal Chawla, MD, chief medical information officer of Raleigh, N.C.-based WakeMed.

WakeMed has cut patient portal messages by 12-15 per provider per day by using generative AI for drafts, removing unnecessary messages, and routing inquiries to other staffers to help, Dr. Chawla said. The health system has also partnered with a company to streamline medication refill requests.

Hershey, Pa.-based Penn State Health dedicates teams to sort messages so they don't all go to physicians, limits characters on portal communications, and directs patients messaging multiple times to virtual visits, according to Chief Medical Information Officer Chris DeFlitch, MD.

"We have to set better expectations with patients that this is not an open email to their provider," said Brett Oliver, MD, chief medical information officer of Louisville, Ky.-based Baptist Health. "While we would love to provide that kind of access, it is just not practical for most. We want our patients to be able to contact us digitally, but we need to educate our patients better on appropriate use."

Baptist Health provides one-button replies to common requests, drafts responses with generative AI, and filters messages to bring the most important ones to the top of the inbox.

"To even more significantly change this situation, I believe operational work needs to occur as well," Dr. Oliver said. "The staff triaging the messages to the providers need the ability, through protocols, to be empowered to the top of their license to answer some messages.

"What can be done with safety and high quality without involving the provider? Too many times, messages are not triaged at all. While the provider can generally answer all the questions, should they?"

A team approach at CommonSpirit

Chicago-based CommonSpirit Health's approach includes team-based inbox management, with advanced practice providers and medical assistants screening messages for physicians; character limits; increased asynchronous care offerings; and patient education on which issues are better for a virtual or in-person visit, said Chief Medical Information Officer John Chelico, MD.

"The inbox is not the responsibility of a single provider. It's a team," he said. "The second thing is we need to understand when the inbox needs to be converted to a regular appointment, whether in person or telehealth.

"If someone says, 'I need a refill with my medication,' it doesn't need to be escalated. If someone says, 'I need to follow up on the lab work that I got last week,' maybe that can be handled by one of the [advanced practice providers]," he said. "If a patient is trying to take care of their chest pain, that's inappropriate."

"There is a disclaimer … don't expect that this inbox message will be responded to immediately or someone's picking up the pager every time you click enter," he added. "There's generally a day or two day turnaround time before every inbox message is being responded to. The risk is that patients have a comfort that I sent the message and now my doctor has it. But you don't know what's happening behind the scenes. Maybe your provider's out. Maybe your provider's sick. That is a risk."

CommonSpirit has decided not to charge patients for patient portal messages because "it's against our mission" and would create a "paywall between the provider and the patients," Dr. Chelico said. "What's better generally is a response in the inbox to say, 'Hey, 'I'd love to help you out. But I think it would be more appropriate for you to schedule an appointment,'" he said.

Messaging is typically more accepted at practices with value-based care agreements, like in CommonSpirit's Northern California market, Dr. Chelico said. CommonSpirit is also piloting Epic's program that drafts patient portal messages with generative AI in the health system's mountain region in Colorado.

UC Davis Health's 'demonstrable decreases'

Physicians working after hours isn't a new issue, said Scott MacDonald, MD, chief medical information officer of Sacramento, Calif.-based UC Davis Health. "I remember bringing home paper charts at night before the EHR," he said.

That said, patients didn't have the perceived access to their physicians that they do now.

"The pandemic really drove the shift toward patient awareness of the possibility of telehealth essentially and doing care outside of the normal setup that we've had for decades: That was, you have to come into the office and have a visit to get healthcare," Dr. MacDonald said.

"So this kind of opened up everybody's eyes: 'Oh, I can just send them an email.' And that matches their experience in other consumer areas. You don't need to call your airline to make a reservation or go to the bank teller anymore. It brought healthcare up to the same kind of consumer expectation level as other industries."

To reduce the deluge of messages, UC Davis Health turned off some automated messaging and hired triage nurses to respond to them. Messages that can't be handled by the nurses then go to physicians, where generative AI first creates a draft response that the providers review.

"A lot of the technology helps, but I think humans are more helpful," Dr. MacDonald said. "Large language models aren't nuanced enough or robust enough and trained on the healthcare data to be able to really evaluate the entire chart and generate a sensible response to the message. It's not there yet."

"I'm sure various vendors are working on it because they all want our data to train the models. That would be a large language model specifically trained on healthcare data, EHR data, that can handle and is capable of ingesting a large amount of healthcare data from actual patients' charts, in orders," he added. "That's something that would really help, but I haven't seen a viable product on that yet."

UC Davis Health has also been crediting physicians for responding to messages outside of work hours, figuring it into their compensation plans, and plans to start billing for MyChart messages.

Early results of these initiatives have been promising.

"The messages that don't come in, frankly, are nice. It's something that you don't really appreciate. There's just less pressure now. My inbox isn't full anymore," Dr. MacDonald said. "And having the triage nurse is very helpful because a lot of the messages they just take care of. I don't need to get as many. I just kind of cosign and say, 'Yeah, that was good advice.' I agree with it and move on to the next thing."

"We have demonstrable decreases in the volume of messages coming in," he added. "We have taken work off people's plates. In fact, it's been difficult to test our draft responses because it doesn't seem like we're getting as many responses to as many messages."

At the same time, patients have been seeking more in-person visits since the pandemic ended, either from care they delayed or previously sought virtually, "so there's little less asynchronous work needed to be done," Dr. MacDonald noted. The Annals of Family Medicine study found that physicians' inbox time has decreased slightly since the pandemic's peak.

UC Davis Health also plans to launch a documentation assistant that uses AI to turn medical jargon or shorthand into language that patients can more easily understand, saving physicians writing time.

Dr. MacDonald said patient portal messaging ultimately boosts health equity. 

"For lower-income patients or patients who can't get away from work or can't get childcare to come see the physician, being able to do video visits or asynchronous work gives them access to healthcare they might not be able to get if they're restricted to coming into the office from 8 to 5," he said. "I would like to see that made more overt: 'Let's provide this care to meet the needs of people suffering disparities.' But we do have to make sure that physicians are getting compensated for this real work that they're doing."

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