The portal paradox   

My patient was struggling. Her beloved husband’s chronic illness had progressed and he could no longer live at home. For the first time in their long marriage, they were separated, and he was living in long-term care. She was writing poetry and drawing to cope with her grief and anxiety. I opened her portal message that had an attachment.  Instead of the usual labs, bills, and x-ray reports, I found a beautiful abstract drawing. I was moved and found myself tearing up.

I’m a primary care physician, and I have a confession: I have a love-hate relationship with the patient portal. Early on, I was an enthusiastic adopter and champion of portal use when it became available to me about 20 years ago. I enjoyed being able to communicate with patients who could use their own words, without the distortion of a message taken by another person, like the child’s game of “telephone.” I liked avoiding phone tag when sharing and discussing results. Patients liked communicating directly without being put on hold and transferred. The portal promoted patient-centered care through direct communication and asynchronous access.

Fast forward to the post-pandemic era. The portal’s positives now often seem outweighed by the sheer volume of messages and patient expectations of an immediate response. For many practitioners, the portal has become a source of frustration rather than a valuable tool. I regret this, as I believe in the power of patient portals to facilitate direct communication, which is at the heart of collaborative and patient-centered care.

Patient portals offer convenience and near-immediate access to medical teams. Their use has risen in the wake of the COVID pandemic with some estimates showing a 57% increase in messages. Patient portal access is associated with greater engagement by patients in their healthcare, but evidence reveals ongoing disparities in portal access and utilization—the digital divide persists. Historically marginalized groups, such as Black, Hispanic, and non-English-speaking individuals, who have faced long-standing challenges in healthcare navigation and carry a comparatively more excessive burden of chronic diseases, remain less likely to use patient portals. As healthcare systems come to rely heavily on the portal, intervention to ensure that all patients have equal access to its benefits is critical. It also begs the question of whether portal messaging distracts us from focusing on the needs of the broader population as the majority of messages come from patients who have greater digital access.

Portal challenges

Among the challenges of the portal for clinicians are the sheer volume of messages as well as the impact on practice workload and, potentially, clinician and team well-being. Research has shown that female-identifying clinicians receive more messages than their male counterparts. Increase in portal messaging by patients is associated with additional time spent on the EHR outside of scheduled hours. Ideally, we should have time built into our schedules to address electronic communication, but most of us do not, and often these messages are answered at the end of the day or after hours. It often seems that portal volumes have outpaced many practices’ capacity to respond.

Colleagues nationally have shared their greatest portal challenges: 1) long and detailed messages, 2) report of symptoms that require further in-depth assessment, 3) incomplete communications that require multiple exchanges to resolve 4) urgent messages, despite organizations’ disclaimers that the portal is not to be used for time-sensitive matters. Often patients have an expectation that their concern should be expeditiously resolved over the portal, even if a clinician is not comfortable doing so.

Potential solutions

It’s important that organizations recognize that no single clinician can possibly manage all messages received and that the messages must be treated like phone calls, with appropriate triage and a team-based approach. The AMA has a practical toolkit that practices can use. These suggestions include:

1. Clear communication of the expected response time to patient messages.

2. Character limits for portal messages (250 to 500 characters).

3. Billing for patient portal messages that require clinical decision-making.

4. Creating a standard patient portal etiquette/user guide communicating use expectations.

As individual practitioners, we can:

1. Send a message or provide a handout to patients describing your personal preferences for patient portal use.

2. Be open and honest with patients if they’re sending too many messages. It may be helpful to set boundaries with them on portal use and instead schedule more regular follow-up appointments to check in.

Educate patients

Since the patient-practitioner relationship is collaborative, patients also must modify their approach to portal use. Here are some things to share with your patients:

1. If your message is time-sensitive, make a phone call instead of sending a message.

2. Type complete messages.

3. Avoid lengthy messages, and/or messages containing more than one concern.

Digital empathy

Finally, teams can practice “digital empathy” that may enhance patient satisfaction and reduce unnecessary messaging. Some tips for doing this include:

1. Reflect back/repeat back the feelings and statements the patient expressed.

2. Use statements that convey you understand their pain, fear, or concern. Use empathetic language. Choose words and phrases that show compassion.

3. Punctuation matters. Repeated punctuation (!!, ??) can be used emphatically to compensate for lack of non-verbal cues, but sender intent and recipient interpretation may vary.

4. Provide clear guidance on the clinical appropriateness of what can and cannot be handled via message. Set clear expectations.

5. Patients should know upfront that you usually won’t and can’t resolve their question within seconds or hours. If a clinic has the capacity, it could be by the end of the day, but there could be instances where it takes longer.

6. I often sign my messages with “take care” or “best.” When conveying results, I will begin with, “I hope this finds you well/feeling better.”

The portal can be an important connection between practitioners and patients, and my hope is that we can return to a place in which it’s a valuable tool and not an impossible extra task. While the sharing of artwork is not a routine use of the portal, fostering patient-centered communication and clinician flourishing should be.

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.