How about those portal messages? Lately, it seems everyone I talk to has something to say about patient portal messages. Patients have opinions, clinicians have opinions, they’re rarely the same opinion. So yes, let’s dig into the phenomenon that I’ve started referring to as the visit after the visit.
Hi everybody, this is 10 Minutes to Better Patient Communication from Health Communication Partners. Since 2017, we’ve been giving you inspiration and strategies to improve engagement, experience, and satisfaction. I’m Dr. Anne Marie Liebel, a researcher, consultant, and educator specializing in communication and education. This podcast makes space to dig into what it’s easy to take for granted about communication in our professional lives, especially in healthcare and public health, but increasingly across sectors because communication touches everything. We’re here to learn and get inspired, but most importantly, make the difference we got into our jobs to make.
Did you know we have a newsletter? You should get it. It’s good. Sign up at healthcommunicationpartners.com.
Yeah, I’ve been planning to podcast about portal messaging for a while because it seems lately it’s such a topic of conversation. It started several months ago when I was talking about patient communication with a nurse who said that the team does active listening, but there can be time with questions after a visit. So it feels like an additional visit on the phone or in my chart. And that’s when I began thinking about what it sounded like she was describing: there’s a visit after the visit.
And since then, it seems more and more people are talking about it. Maybe I’m just noticing it more. But in late June, so just this past summer, a major national study on this came out of NYU Langone. It’s in JAMA. So let’s look into this visit after the visit.
It’s not hard to imagine why patients like portal messages. You’ve got direct access, right? No waiting room, no time off work. The NYU study found that, yep, at least 12% of Americans now communicate with their health care providers in this way. They also found that online portal messages sent to providers more than doubled between 2020 and 2025. The study’s senior investigator, Michael Mankowski, said in a news release, “Our study shows that use of patient portals, health apps, and messaging are now a routine part of everyday patient care across America, not simply side channels used occasionally.”
Health systems also have incentives to expand the use of portal messaging. There’s customer service, right? This is great customer service. You’ve got patient experience scores, patient satisfaction scores, digital access itself is a competitive advantage, right? If you’re a health system that offers less digital access than the academic center down the road, you risk losing a patient that expects it.
I don’t know about you, but when I go to my health system, after that visit, I get the text that says, “thanks for coming. If you have any unanswered questions, call this number or message us in the portal.”
How did we get here? What’s the origin story? Well, You can trace the portal messaging back to the HITECH Act’s Meaningful Use program, and that was run through CMS in 2011. Yeah, 15 years ago. Basically, portal messaging exists in essentially every EHR today because of that. They tie provider incentive payments and eventually penalties to using certified EHR technology, and secure messaging with patients was one of the specific required objectives.
That’s the origin, and it explains why the feature exists, though it’s possible nobody knew what would happen once patient adoption actually took off like a decade later. Largely, I think a lot of people are hypothesizing, because of COVID.
So the key finding from the NYU study is interesting. They wondered if, after the COVID surge toward portal use and digital messages, would it decrease? Well, it didn’t. Not only did it not decrease, it increased. Almost more than doubled, 153% increase in patient authored messages from 2020-2025. They also wondered if the digital visits would replace in-person visits and phone calls. Phone calls did go down a little bit over that same time. But in-person visits did not go down. In fact, in-person visits went up. So then, researchers stated that they think portal messaging functions as an expansion of care between visits. So it’s not a substitute for in-person care, but a supplement to in-person care.
But this additional access is not evenly distributed. That same study found that the heaviest users are 86% from urban areas, They are 61% women, skewing – the largest third is between 40, ages 40 and 64. Another finding was that one in three patients from the least vulnerable neighborhoods used messaging, versus roughly one in four from the most vulnerable. This indicates that lower use of portal messaging among patients living in socially vulnerable neighborhoods might widen existing access gaps. And the researchers note that in the study. Of course, link in the notes.
A separate study from Columbia’s Mailman School found that patients from historically marginalized groups were generally less likely to receive a response to their message at all. And specifically less likely to hear back from the intended recipient, most often their physician. This is from 2024, and that study also had a follow-up study that was just published a couple weeks ago. Links in the notes.
So care delivery patterns may be permanently shifting, though unevenly. The visit after the visit might be here to stay, and care teams know it.
I was talking to a nurse practitioner who said, our patients are on the portal 24-7. And the data backs this up. Primary care physicians can see up to 2.6 hours of additional after-hours EHR work outside the clinic due entirely to a high volume of patient portal messages. This is from a UCSF study in Health Affairs, also out just a couple weeks ago.
So a portal message that’s read and answered by a physician after hours, that’s absorbed into salary. So this is unpaid time. I’ve heard it called “pajama time.” Multiple studies have tied portal messaging to burnout, and it’s not hard to see why.
So when you put these statistics together with the NYU study findings, the scope of the impact of the visit after the visit starts to be massive. And this is a real bind, because patients genuinely do appreciate the ability to message care teams. Institutions, like I said, they want to extend it. But now you’ve got the care teams who are dealing with this tidal wave.
And my lens is from patient communication from both sides. So along with AI, I’m wondering if the visit after the visit might be the biggest shift in patient communication that we’ve seen since social media.
Now it’s still kind of a moving target, and a lot is happening, but there are some approaches being proposed. The NYU study in JAMA was accompanied by a commentary. And the commentary said that, “Asynchronous communication, while convenient for patients, may contribute to unsustainable workloads.” And as you know, there’s already a workforce shortage. So the authors mentioned several policy recommendations, including on staffing models, time, reimbursement, evaluating your portal policies, scrutinizing AI tools for downstream effects.
There are layers and layers of this that are interesting to me as a language and literacy researcher. One of a few places I’m paying attention to is the modality of messaging itself. Whether messaging as a communication mode, with its own kind of informal grammar, doesn’t quite fit the clinical context, but I’m going to save that for another episode.
Another question, yes, what can we do about this, the visit after the visit? I’ve been in early conversations with a care team about exactly this. And those conversations have really been useful for me for understanding where you’re feeling it most. So as usual, I’m going to end with something you can do.
This is going to be about data. Because if this is a real structural change, like the JAMA editorial says it is, this change came before most teams had a chance to plan for it. Maybe your practice has already started pulling data. If so, I’d love to hear about it. Get in touch with me. If not, here’s four data points you might want to grab, to start wrapping your head around this tidal wave of messaging.
- Message volume and rate.
- Time. Time spent, including those after-hours pajama time.
- Who’s sending, who’s answering.
- What’s actually in the messages.
In the studies I’ve seen, these are some of the most common data points talked about. These four together should give your team enough to start asking follow-up questions and inform next steps before anything else.
I am curious where your teams are with this. What does your visit after the visit landscape look like? What are you learning from looking at it? Find me on LinkedIn or visit healthcommunicationpartners.com. This has been 10 Minutes to Better Patient Communication from Health Communication Partners. Audio engineering and music from Joe Liebel. Additional music from Alexis Rounds.
